OB: High-Risk Preg Part I

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?

"Come to the health facility with any vaginal material passed." Explanation: This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so it can be assessed for this.

A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse?

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid." Explanation: The practitioner will perform a speculum examination, looking for pooling of amniotic fluid, and then test the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. Preterm premature rupture of membranes occurs when the rupture of the amniotic sac before the onset of labor happens in a woman who is less than 37 weeks' gestation.

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?

"Purse-string sutures are placed in the cervix to prevent it from dilating." Explanation: The cerclage, or purse string suture is inserted into the cervix to prevent preterm cervical dilatation and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dila

A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding Explanation: The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placenta.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm/Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?

Palpate the fundus, and check fetal heart rate. Explanation: The classic signs of abruptio placentae are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

A woman with severe preeclampsia is receiving magnesium sulfate. The woman serum magnesium level is 9.0mEq/L. Which finding would the nurse most likely note?

diminished reflexes Explanation: Diminished or absent reflexes occur when a client develops magnesium toxicity, serum levels greater than 8.0 mEq/L. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.

A woman with a recent incomplete abortion is to receive therapeutic misoprostol. The nurse understands that the rationale for administering this drug is to:

ensure passage of all the products of conception. Explanation: Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an incomplete abortion to ensure passage of all the products of conception. Rh (D) immunoglobulin is used to suppress the immune response and prevent isoimmunization.

What would be the physiologic basis for a placenta previa?

low placental implantation Explanation: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy?

methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A client for has an Rh-negative blood type. Following the birth of the client's infant, the nurse administers her Rho(D)immune globulin. The purpose of this is to:

prevent maternal D antibody formation. Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies

A client suffering a miscarriage at 12 weeks' gestations is very upset that the health care provider has ordered a D&C. How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?

"This procedure is needed to adequately remove all the fetal tissue." Explanation: By this stage of pregnancy, the placenta has adhered to the uterine wall. This was not the case when the client was only 5 weeks pregnant. The total removal of the products of conception will be needed to ensure healing and prevent excessive bleeding and infection.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?

Correct response: Monitor the client's vital signs and bleeding. Explanation: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending abortion. Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

Correct response: assessing fetal heart tones by use of an external monitor Explanation: Not disrupting the placenta is a prime responsibility. An internal monitor, a vaginal examination, and remaining ambulatory could all do this and thus are contraindicated.

A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse anticipate preparing the patient?

Immediate surgery Explanation: An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The patient does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the patient is not in labor.

A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which measure will be important for the nurse to include in the care plan?

Institute and maintain seizure precautions. Explanation: The woman with severe preeclampsia should be maintained on complete bed rest in a dark and quiet room to avoid stimulation. The client is at risk for seizures; therefore, institution and maintenance of seizure precautions should be in place.

The nurse is monitoring a pregnant patient who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do?

Stop the current infusion. Explanation: When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent.

A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination there is an elevated hCG level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?

gestational trophoblastic disease Explanation: The client is most likely experiencing gestational trophoblastic disease or a molar pregnancy. In gestational trophoblastic disease or molar pregnancy, there is an abnormal proliferation and eventual degeneration of the trophoblastic villi. The signs and symptoms of molar pregnancy include brownish vaginal bleeding, elevated hCG levels, discrepancy between the uterine size and the gestational age, and absent fetal heart sounds. Abruption of placenta is characterized by premature separation of the placenta. Ectopic pregnancy is a condition where there is implantation of the blastocyst outside the uterus. In placenta previa the placental attachment is at the lower uterine segment.

A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated?

phrenic nerve irritation Explanation: The symptoms if rupture or hemorrhaging occurs before successfully treating the pregnancy are lower abdomen pain, feelings of faintness, phrenic nerve irritation, hypotension, marked abdominal tenderness with distension, and hypovolemic shock. Painless bright red vaginal bleeding occurring during the second or third trimester is the clinical manifestation of placenta previa. Fetal distress and tetanic contractions are not the symptoms observed in a client if rupture or hemorrhaging occurs before successfully treating an ectopic pregnancy.

A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?

pregnancy loss Explanation: The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for pregnancy loss. Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.

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. Explanation: 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.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

Correct response: assessing the amount and color of the bleeding Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

The nurse is identifying nursing diagnoses for a patient with gestational hypertension. Which diagnosis would be the most appropriate for this patient?

Ineffective tissue perfusion related to vasoconstriction of blood vessels Explanation: In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.

A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?

Respiratory rate Explanation: The level of magnesium in therapeutic range is 4 to 8 mg/dL. If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the patient to do at this time?

Seek immediate medical attention and bring the expressed vaginal material. Explanation: Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. At approximately week 16 of pregnancy, vaginal bleeding will begin as spotting of dark-brown blood accompanied by discharge of the clear fluid-filled vesicles. The pregnant patient who begins to miscarry at home needs to bring any clots or tissue passed to the hospital because the presence of clear fluid-filled cysts identifies gestational trophoblastic disease. The patient needs to seek immediate medical attention and not stay at home on bed rest, count perineal pads, or continue with normal activity and count pulse rates every hour.

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse will continue to monitor this client for which condition?

Severe preeclampsia Explanation: This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of the betamethasone is to try and hasten the maturity of the fetus's lungs for birth. The client has already progressed from mild preeclampsia to severe preeclampsia and measures need to be followed to prevent advancement of the disease process. The scenario described does not indicate a client with hypertension.

A pregnant patient with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful?

The client delivers a full-term fetus at 39 weeks' gestation. Explanation: Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. CC: use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy.

A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90 mm Hg. Her urine is negative for proteinuria. The nurse recognizes which factor as the potential cause?

gestational hypertension Explanation: Gestational hypertension is characterized by hypertension without proteinuria after 20 weeks of gestation resolving by 12 weeks postpartum. defined as :systolic blood pressure of greater than 140 mm Hg and/or diastolic of greater than 90 mm Hg on at least two occasions at least 6 hours apart after the 20th week of gestation, in women known to be normotensive prior to this time and prior to pregnancy. HELLP is an acronym that refers to hemolysis, elevated liver enzymes, and low platelets. Preeclampsia may result if hypertension is not controlled or advances to a more severe state.

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension Explanation: Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Abruptio placenta (separation of the placenta from the uterine wall), placenta previa (placenta covering the cervical os), and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What would be the most likely cause of these symptoms?

premature separation of the placenta Explanation: Premature separation of the placenta begins with sharp fundal pain, usually followed by vaginal bleeding. Placenta previa usually produces painless bleeding; labor contractions are more often described as cramping.

When assessing a pregnant woman with vaginal bleeding, the nurse would suspect a threatened abortion based on which finding?

slight vaginal bleeding Explanation: Slight vaginal bleeding early in pregnancy, no cervical dilation, and a closed cervical os are associated with a threatened abortion. Strong abdominal cramping is associated with an inevitable abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.