Chapter 23 Risk conditions related to pregnancy

RN is assessing a pregnant client w/type 1 DM about an understanding regarding changing insulin needs during pregnancy. Further teaching is needed if the client says 1)I will need to increase my insulin the first 3 mons of pregnancy. 2)My insulin dose will probably need to be increased the 2nd & 3rd trimesters 3)Episodes of hypoglycemia are more likely to occur during the first 3 mons of pregnancy 4) insulin needs return to prepregnant levels 7-10 days after birth if i bottle feed

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." Rationale: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of the diabetes during pregnancy.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse would prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1. Delivery of the fetus Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1. Hypertension 2. Low-grade fever 3. Generalized edema 4. Increased pulse rate

1. Hypertension Rationale: A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.

The nurse is providing instructions to a pregnant client with HIV infection regarding care of the newborn after delivery. The client asks the RN about the feeding options available. Which response would the nurse make to the client? 1. bottle-feed your newborn. 2. feed your newborn by nasogastric tube feeding. 3. breast/chest-feed for 6 months and then will need to switch to bottle-feeding. 4. breast/chest-feed for 9 months and then will need to switch to bottle-feeding.

1. You will need to bottle-feed your newborn. Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the birthing parent is breast/chest-feeding. Clients who have HIV will most likely be advised not to breast/chest-feed; however, the PHCP's recommendations regarding breast/chest-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse in a maternity unit is reviewing the clients' records. Which clients would the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? SATA 1.A primigravida w/ abruptio placentae 2.A primigravida who delivered a 10-lb infant 3 hrs ago 3.A gravida 2 who has just been dx'd w/ dead fetus syndrome 4.A gravida 4 who delivered 8 hrs ago & lost 500 mL of blood 5.A primigravida 29 weeks gestation w/ new dx gestational hypertension

1.A primigravida with abruptio placentae 3.A gravida 2 who has just been diagnosed with dead fetus syndrome 5.A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Rationale: In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The clinic nurse is performing a psychosocial assessment of a client who is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting HIV? SATA 1.The client has a hx of IV drug use. 2.The client has a significant other who is heterosexual. 3.The client has a hx of sexually transmitted infections. 4.The client has had one sexual partner for the past 10 years. 5.The client has past hx of gestational DM

1.The client has a history of intravenous drug use. 3.The client has a history of sexually transmitted infections. Rationale: HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected birthing parent to the fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

A client in the 1st tri of pregnancy reports experiencing vaginal bleeding. A threatened abortion is suspected, and the RN instructs the client regarding management of care. Which statement indicates a need for further instruction? 1. watch to see if I pass any tissue 2. maintain strict bed rest throughout the remainder of the pregnancy 3. count the # of perineal pads used daily; note amount and color of blood on the pad 4. avoid intercourse until bleeding stops and 2 weeks after last episode

2. "I will maintain strict bed rest throughout the remainder of the pregnancy." Rationale: Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client needs to watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage Rationale: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.

A pregnant client reports to a health care clinic, c/o of loss of appetite, cough, weight loss, fatigue. After assessment of the client, TB is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction would the nurse include in the client's teaching plan? 1. Therapeutic abortion is required. 2. Isoniazid plus rifampin will be required for 9 months. 3. The client will have to stay at home until treatment is completed. 4. No meds until fetus is born

2. Isoniazid plus rifampin will be required for 9 months. Rationale: More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and would question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal h

2. Obtain equipment for a manual pelvic examination. Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, which is at risk for severe hypoxia.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2. Uterine tenderness Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.

The RN is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs would the nurse anticipate? SATA 1.Bed rest as a necessary preventive measure may be prescribed. 2.Administration of SUBQ heparin post-delivery as prescribed. 3.An overbed lift may be necessary if the client requires a c-section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stocking or SCD may be prescribed

2.Administration of SUBQ heparin post-delivery as prescribed. 3.An overbed lift may be necessary if the client requires a c-section. 5.Thromboembolism stockings or sequential compression devices may be prescribed. Rationale: The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for c-section and requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly who required c-section, frequent and early ambulation (not bed rest), prior to/after surgery. Routine administration of prophylactic pharmacological venous thromboembolism medications (heparin) commonly prescribed. Overbed lift may be needed to transfer a client from an operating table to bed if c-section is necessary. Increased monitoring & cleansing of incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or SCDs decrease risk for blood clots.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I need to stay on the diabetic diet." 2. "I need to perform glucose monitoring at home." 3. "I need to avoid exercise because of the negative effects on insulin production." 4. "I need to be aware of any infections and report signs of infection immediately to my obstetrician."

3. "I need to avoid exercise because of the negative effects on insulin production." Rationale: Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. increase my sodium intake during pregnancy 2. lower my blood volume by limiting my fluids 3. maintain a low-calorie diet to prevent any weight gain 4. drink adequate fluids and increase my intake of high-fiber foods

4. "I need to drink adequate fluids and increase my intake of high-fiber foods." Rationale: Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium needs to be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura

4. Evidence of bleeding, such as in the gums, petechiae, and purpura Rationale: Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and needs to be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

RN evaluates the ability of a hep. B + birthing parent to provide safe bottle-feeding to the newborn during postpartum hospitalization. Which action best exemplifies the birthing parent's knowledge of potential disease transmission to the newborn? 1. requests that the window be closed before feeding. 2. holds the newborn properly during feeding/burping. 3. tests the temp of the formula before initiating 4 washes/dries hands before/after self-care of perineum; asks for gloves before feeding

4. The birthing parent washes and dries the hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Rationale: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce complications in the birthing parent. The correct option provides the best evaluation of client understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision.

4. The client complains of a headache and blurred vision. Rationale: If the client complains of a headache and blurred vision, the PHCP needs to be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation, as the blood penetrates the myometrium and causes uterine irritability.