Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

Assess the client's vital signs. A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia?

Have her blood pressure checked at every prenatal visit. Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

elevated liver enzymes hemolysis low platelet count The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.

A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

A transvaginal ultrasound For any pregnant woman who presents with painless bleeding, placenta previa needs to be ruled out by either transvaginal or abdominal ultrasound. A digital cervical exam is contraindicated until placenta previa has been ruled out, as digital manipulation of placental tissue through the cervical os can cause uncontrollable bleeding. The nonstress test and electronic fetal monitoring would be utilized after the woman is stabilized and placenta previa has either been diagnosed or ruled out.

The nurse is assessing a client at 12 weeks' gestation at a routine prenatal visit who reports something doesn't feel right. Which assessment findings should the nurse prioritize?

gestational hypertension, hyperemesis gravidarum, absence of FHR The early development of gestational hypertension/preeclampsia, hyperemesis gravidarum, and the absence of FHR are suspicious for gestational trophoblastic disease. The elevated levels of hCG lead to the severe morning sickness. There is no fetus, so FHR, quickening, and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased.

The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?

"If I have changes in my vision, I will lie down and rest." Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampsia and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia. The other choices are instructions which the client may be given to follow.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best?

"Please come in now for an evaluation by your health care provider." Explanation: Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy?

Abdominal ultrasound An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.

A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?

Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.

A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)?

Onset of vaginal bleeding was sudden and painful Explanation: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.

The nurse is caring for a woman at 32 weeks' gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client?

Tachycardia Explanation: Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision (halos around lights), or sweating. Magnesium sulfate may cause sweating.

A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially?

normal saline For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.

A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?

preterm rupture of membranes followed by preterm birth Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

reflexes Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.

The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education?

signs of preterm labor The client with a multifetal pregnancy must be made aware of the risks posed by preterm labor. There is no corresponding increase in the risk for hypertension or blood incompatibilities. Parenting skills are secondary to physiologic needs at this point.

A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize?

urine output of less than 15 ml/hr Explanation: Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 500 mg in 24 hours, oliguria of less than 15 ml/hr, cerebral and visual symptoms, and rapid weight gain. Mild facial edema or hand edema occurs with mild preeclampsia. A urinary output of 15 ml/hr would result in an output of 360 ml/24 hours, which would be below the recommended range and should be reported. Ankle edema of 1+ could be related to regular pregnancy and not necessarily just severe preeclampsia. A finding of 3+ to 4+ pitting edema would be more alarming and require intervention.

An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate?

Contact the health care provider to report the client's feelings. The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family.

An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a spontaneous abortion (miscarriage). Which action by the nurse is most appropriate?

Contact the health care provider to report the client's feelings. The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy and needs to be monitored, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to remain silent about her feelings may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate because the scenario described does not indicate that the nurse has the client's permission to share this information with her family.

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next?

Notify the health care provider Explanation: The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.

A pregnant client with preeclampsia with severe features has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?

observation for bleeding Explanation: Because of the low platelet count associated with this condition, women with HELLP syndrome need extremely close observation for bleeding, in addition to the observations necessary for preeclampsia. Maintaining a patent airway is a critical intervention needed for a client with eclampsia while she is having a seizure. Administration of a tocolytic would be appropriate for halting labor. Monitoring for infection is not a priority intervention in this situation.