Pregnancy Complications: NCLEX
When performing an assessment on a neonate, which assessment finding is MOST SUGGESTIVE of hypothermia? 1. bradycardia 2. hyperglycemia 3. metabolic alkalosis 4. shivering
1. bradycardia hypothermic neonates become bradycardic proportional to the degree of core temp HYPOGLYCEMIA is seen in HYPOTHERMIC NEONATES Shivering is rarely observed in neonates metabolic ACIDOSIS, not alkalosis is seen due to slowed resp
Which of the following factors would contribute to a high risk pregnancy? 1. Blood type O positive 2. first pregnancy at age 33y.o. 3. Hx of allergy to honey bee pollen 4. Hx of insulin dependent DM
4. a woman w/ a hx of diabetes has an increased risk for perinatal complications, including HTN, preeclampsia, and neonatal hypoglycemia. The age of 33 years w/out other risk factors doesn't increase risk, nor does type O positive blood or environmental allergens.
A client, 34 weeks pregnant, arrives at the ER with SEVERE abdominal pain, uterine tenderness and an increased uterine tone. The client denies vaginal bleeding. The external fetal monitor shows fetal distress with severe, variable decels. The client most likely has which of the following? 1. Abruptio Plantae 2. Placenta Previa 3. Molar Pregnancy 4. Ectopic Pregnancy
1. Abruptio placentae a client w/ severe abruptio placentae will often have SEVERE abdominal pain. The uterus will have increased tone w/ little to no return to resting tone btw/ contractions. The fetus will start to show signs of distress, with decels in the HR or even fetal death w/ large placental separation. Placenta previa usually involves PAINLESS vaginal bleeding w/out UCs. A molar preg. generally would be detected before 34 weeks gestation. An ecoptic preg. which usually occurs in the FALLOPIAN TUBES, would rupture well before 34 weeks gestation
A client is 33 weeks pregnant and has had diabetes since she was 21. When checking her fasting blood sugar level, which values indicate the clients disease was controlled. 1. 45 mg/dl 2. 85 mg/dl 3. 120 mg/dl 4. 136 mg/dl
2. 85 mg/dl recommended fasting blood sugar levels in pregnant clients w/ dm are 60-90 mg/dl a fasting blood sugar level of 45mg/dl is low and may result in hypoglyecemia a bs level below 120mg/dl is recommeded for 1hour postprandial values a bs level above 136 mg/dl in a pregnant client indicates hyperglycemia
A 17 y.o. primpigravida with severe PIH has been receiving mag sulfate IV for 3 hours. The latest assessment reveals DTR of +1, BP 150/100 mmgHg, pulse 92 bpm, respiratory rate 10bpm and urine output 20ml/hr. Which of the following actions would be most approp? 1. Continue monitoring per standards of care 2. Stop the mag sulfate infusion 3. Increase infusion by 5gtt/min 4. Decrease infusion by 5gtt/min
2. Stop the mag sulfate infusion Mag sulfate should be withheld if the clients resp rate or urine output falls or if reflexes are diminished / absent. The client also shows other signs of impending toxicity such as flushing / feeling warm. Inaction wont resolve the clients suppressed DTRs and low RR / urine output. The client is already showing CNS depression bc of excessive magsulfte so increasing the infusion is wrong. Impending toxicity indicates that the infusion should be stopped rather than just slowed down.
a 21 y.o. client, 6 weeks pregnant, is diagnosed with hyperemesis gravidum. This excessive vomiting during pregnancy will often result in which of the following? 1. bowel perforation 2. electrolyte imbalance 3. miscarriage 4. PIH
2. ELECTROLYTE IMBALANCE Excessive vomiting in clients with hyperemesis grav often causes weight loss / fluid and electrolyte, acid base imbalance. PIH and bowel perforation arent r/t hyper grav the effects of hyper grav on the fetus depend on the severity of the disorder. clients w/ severe hyper grav may have low birth weight infant, but the disorder isnt life threatening to the fetus.
Which of the following conditions isnt dx by abdominal US during the prenatal period? 1. fetal presentation 2. fetal heart activity 3. maternal diabetes 4. amniotic fluid volume
3. maternal diabetes abdominal US evals fetal presentation, fetal heart activity, amniotic fluid volume although it may show increased amnitoic flud, thus helping to diagnose maternal diabetes, it isnt used for that purpose.
A 21y.o. client has been diagnosed with hydatidiform mole. Which of the following factors is considered a risk factor for developing hydatidiform mole? 1. age in 20s or 30s 2. high in SES 3. Primigravida 4. prior molar gestation
4. previous molar gestation increases risk for developing subsequent molar gestation by 4-5 times. Adolescents and women ages 40+ are at increased risk for molar pregs. MULTIGRAVIDAS, esp women with prior preg loss, and women with LOWER SES are at increased risk for this problem.
Which assessment finding would be the most unlikely risk factor for RDS 1. second born of twins 2. neonate born at 34 weeks 3. neonate of diabetic mom 4. chronic maternal HTN
4. CHRONIC MATERNAL HTN unlikely factor bc chronic fetal stress tends to INCREASE LUNG MATURITY premature neonates < 35 weeks are associated with RDS Even with a mature lecithin to sphingomyelin ration, neonates of moms with diabetes still develop RDS 2nd born of twins may be prone to greater risk of asphyxia
Neonates born to women infected with hepatitis B should undergo which Tx regimen 1. Hep B vaccine at birth and 1 month 2. Hep B immune globulin at birth, no hepatitis B vaccine 3. Hepatits B immune globulin within 48 hours of birth and Hep B vaccine at 1 month 4. Hep B immune globulin within 12 hours of birth and Hep B vaccine at birth, 1 month, 6 months
4. Hep B immune globulin within 12 hours of birth and Hep B vaccine at birth, 1 month, 6 months Hep B immune globulin should be given as soon as possible after birth but within 12 hours neonates should also receive hep B vaccine at regularly scheduled intervals this sequence of care has been determined as superior to the others
Because uteroplacental circulation is compromised in clients with preeclampsia, a NST is performed to detect which conditions? 1. Anemia 2. Fetal well being 3. IUGR 4. oligohydarminos
An NST is based on the theory that a healthy fetus will have transient fetal heart rate accelerations with fetal movement. A fetus with compromised uteroplacental circulation usually wont have these accelerations, which indicate a nonreactive NST. Serial US wil detect IUGR and oligohydramnios in a fetus. An NST cant detect anemia in a fetus
A client who is 32 weeks pregnant is being monitored in the antepartum unit for PIH. She suddenly complains of continuous abdominal pain and vaginal bleeding. Which of the following nursing internventions should be included in the care of this client? Check all that apply 1. Evaluate VS 2. Prepare for vaginal delivery 3. Reassure client that she'll be able to continue pregnancy 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O
1. Evaluate VS 4. Evaluate FHT 5. Monitor amt of vaginal bleed 6. Monitor I&O The clients Sx indicate that she's experiencing abruptio placenta. The nurse must immed eval the moms well being by eval VS, FWB, by auscultation of heart tones, monitoring amt of blood loss and eval the vol status by measuring I&O. After the severity of the abruption has been determined and blood and fluid have been replaced, prompt C-SECTION delivery of the fetus (not vaginal) is indicated if the fetus is in distress
a client is being admitted to the antepartum unit for hypovolemia secondary to hyperemesis gravidarum. WHich of the following factors predisposes a client to the development of this? 1. trophoblastic disease 2. maternal age > 35 y.o. 3. malnourished or underweight clients 4. low levels of HCG
1. Trophoblastic disease is associated w/ hyperemesis grav obesity and maternal age younger than 20 y.o. are risk factors too. High levels of estrogen HCG have also been associated with the development.
A clients labor doesnt progress. After ruling out CPD, the doctor orders IV admin of 1,000 ml normal saline w/ Pitocin 10 units to run at 2 miliunits / min. 2 miliunits/min is equivalent to how many ml/unit 1. 0.002 2. 0.02 3. 0.2 4. 2.0
3 = 0.2 each unit of oxytocin contains 1,000 miliunits. Therefore, 1,000 ml of IV fluid contains 10,000 miliunits (10 units) of Pitocin
A client at 42 weeks gest is 3cm dilated, 30% effaced, with membranes intact and the fetus at +2 station. FHR is at 140-150 bpm. After 2 hours, the nurse notes on the EFM that, for the past 10 min, the FHR ranged from 160-190bpm. The client states that her baby has been extremely active. UCs are strong, occurring every 3-4 min. and lasting 40-60 sec. Which of the following findings would indicate fetal hypoxia? 1. Abnormally long UCs 2. Abnormally strong uterine intensity 3. Excessively frequent contractions with rapid fetal movement 4. Excessive fetal activity and fetal tachycardia
4. Excessive fetal activity and fetal tachycardia Fetal tachycardia and excessive fetal activity are the FIRST SIGNS OF FETAL HYPOXIA The duration of UCs is w/in normal limits. Uterine intensity can be mild-strong and still be w/in normal limit. The frequency of contractions is w/in normal limits for the active phase of labor.
A woman who's 36 weeks pregnant comes into the labor & delivery unit with mild contracts. Which of the following complications should the nurse watch out for when the client informs her that she has placenta prevue? a. sudden rupture of membranes b. vaginal bleeding c. emesis d. fever
b. vaginal bleeding contractions may disrupt the microvascular network in the placenta of a client with placenta prevue and result in bleeding. If the separation of the placenta occurs at the margin of the placenta, the blood will escape vaginally. Sudden rupture of the membranes isn't related to placenta prevue. Fever would indicate an infectious process, and emesis isn't related to placenta previa
A woman who's 36 week preg comes into L&D with mild contractions. Which of the following complications should the nurse watch for when the client informs her that she has placenta previa? 1. sudden ROM 2. Vaginal bleeding 3. emesis 4. fever
2. Vaginal bleeding contractions may disrupt the microvascular network in the placenta of the client with placenta previa and result in bleeding. if the separation of the placenta occurs at the margin of the placenta, the blood will escape vaginally. sudden ROM isnt r/t placenta previa fever would indicate an infections process, and emesis isnt r/t placenta previa
Clients with gestational diabetes are usually managed by which of the following therapies? 1. diet 2. long acting insulin 3. oral hypoglycemic drugs 4. oral hypoglycemic drugs/insulin
1. diet oral hypoglycemics are contraindicated in preg. long acting insulin usually inst needed for blood glucose control in the client with GDM
A 21 y.o. has arrives to the ER with c/o cramping abdominal pain and mild vaginal bleeding. Pelvic exam shows a left adnexal mass that's tender when palpated. Culdocentesis shows blood in the culdesac. This client probably has which of the following conditions? 1. Abruptio placentae 2. Ecoptic pregnancy 3. Hydatidiform mole 4. Pelvic Inflammatory Disease
2. Ecoptic pregnancy most ecoptic pregnancies dont appear as obvious life threatening med emergencies. THey must be considered in any sexually active woman of childbearing age who c/o menstrual irregularity, cramping abdominal pain, and mild vaginal bleeding. PID, abruptio placentae and hydatidiform moles wont show blood in the cul de sac
Which of the following is best to monitor a fetus of a client with diabetes in her 3rd trimester 1. US exam weekly 2. NST 2x/week 3. Daily contraction stress test at 32 weeks 4. monitoring fetal activity by client weekly
2. NST 2X/week NST is the preferred antepartum HR screening test for pregnant clients with diabetes. NSTs should be done at least 2x per week staring at 32 weeks gestation, as fetal deaths in clients w/ diabetes have been noted within 1 week of a reactive NST. US should be done ever 4-6 weeks to monitor fetal growth. CST wouldnt be initiated at 32 weeks Maternal fetal activity monitoring should be done daily
A client at 33 weeks gestation and leaking amniotic fluid is place on an EFM. The monitor indicates uterine irritability and contractions occuring every 4-6 min. The doctor orders terbutaline. Which of the following teaching statements is approp for this client? 1. This medicine will make you breathe better 2. You may feel fluttering or tight sensation in your chest 3. This will dry your moth and make you thirsty 4. You'll need to replace potassium lost by this drug
2. You may feel fluttering or tight sensation in your chest A fluttering or tight sensation in the chest is a common adverse reaction to terbutaline It relives bronchospasm but the client is getting it to reduce uterine motility. Mouth dryness and thirst occur w/ the inhaled form but are unlikely with subcut form Hypokalemia is a potential adverse reaction following large doses of terbutaline but not at doses of 0.25 mg
The nurse receives an order to start an infusion for a client whos hemorrhaging due to a placenta previa. What supplies will be needed? 1. Y tubing, normal saline solution, and 20G cathether 2. Ytubing, lactated Ringers solution and 18G cath 3. Y tubing, normal saline, 18G cath 4. Y tubing, lactated RIngers, 20G cath
3. Y tubing, normal saline, 18G cath blood transfusions require Y tubing Normal Saline solution to mix with the blood product and an 18G cath to avoid lysing breaking the RBCs. A 20G cath lumen isnt large enough for a blood transfusion. Lactated RIngers solutions isnt the IV solution of choice for blood transfusions
WHich finding might be seem in a neonate suspected of having an infection? 1. flushed cheeks 2. increased temp 3. decreased temp 4. increased activity level
3. decreased temp temp instability esp when it resutls in low temp in the neonate, may be a sign of infection. the neonate's color often changes with an infection process but generally becomes ashen or mottled the neonate w/ an infection will usually show a decrease in activity level or lethargy
A client has just given birth at 42 weeks gestation. When assessing the neontate, which phsycial finding is expected? 1. a sleepy, lethargic baby 2. lanugo covering body 3. desquamation of the epidermis 4. vernix caseosa covering the body
3. desquamation of the epidermis postdate fetuses lose the vernix caseosa and the epidermis may become desquamated these neonates are usually VERY alert lanugo is missing in the postdate neonate
Which nursing ntervention helps prevent evaporative heat loss in the neonate immed after birth? 1. admin warm oxygen 2. controlling drafts in the room 3. immed drying the neonate 4. placing neonate on a warm, dry towel
3. immed drying the neonate decreases evaoporative heat loss from moist body from birth placing the neonate on a warm, dry towel decreases CONDUCTIVE losses. controlling draft in the room and admin warm oxygen helps reduce CONVECTIVE LOSS
3 day old neonate needs phototherapy for hyperbilirubinemia. nursery care of a neonate getting phototherapy would include which nursing intervention? 1. tube feedings 2. feeding the neonate under phototheraphy lights 3. mask over the eyes to prevent retinal damage 4. temp monitored every 6 hours during phototherapy
3. mask the neonate's eyes must be covered with eye patches to prevent damage the mouth of the neonate doesnt need to be covered the neonate can be removed from the lights and held for feeding the neonates temp should be monitored at least every 2-4 hours due to risk of hyperthermia w/ phototherpahy
A neonate has been diagnosed with caput succedaneum. which statement is true? 1. usually resolves in 3-6 weeks 2. collection of blood btw/ skill and periosteum 3. doesnt cross the cranial suture line 4. it involves swelling of the tissue over the presenting part of the head
4. it involves swelling of the tissue over the presenting part of the head due to sustained pressure this boggy edematous swelling is present at birth, CROSSES the suture line occurs in occipital area a cephalohematoma is a collection of blood btw/ the skill and periosteum that DOESNT cross the suture lines and resolves in 3-6 weeks caput seccedaneum resolves within 3-4 DAYS
Which Sx would indicate the neonate was adapting approp to extrauterine life w/out difficulty? 1. nasal flare 2. light audible grunting 3. resp rate 40-60 breaths/min 4. resp rate 60-80 breaths/min
4. resp rate of 40-60 breaths/min is normal for a neonate during the transitional period nasal flaring, resp rate > 60 and audible grunting = SIGNS OF RESP DISTRESS!
Which of the following complications can be potentially life threatening and can occur in a client receiving a tocolytic agent? 1. diabetic ketoacidosis 2. hyperemesis gravidarum 3. pulmonary edema 4. sickle cell anemia
3. pulmonary edema Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Clients who dont have diabetes dont need to be observed for diabetic ketoacidosis. Hyperemesis gravidium doesnt result from tocolytic use. Sickle cell anemia is an inherited genetic condition and doesnt develop spontaneously
The SGA neonate is at increased risk during the transitional period for which complication? 1. anemia probably due to chronic fetal hypoxia 2. hyperthermia due to decreased glycogen stores 3. hyperglycemia due to decreased glycogen stores 4. polycythemia probably due to chronic fetal hypoxia
4. polycythemia probably due to chronic fetal hypoxia the SGA baby is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia the neonates are also at increased risk for developing hypoglycemia due to decreased glycogen stores
The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? a. Painless vaginal bleeding b. Abdominal cramping c. Throbbing pain in the upper quadrant d. Sudden, stabbing pain in the lower quadrant
Answer D is correct. The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, abdominal cramping is a sign of labor, and throbbing pain in the upper quadrant is not a sign of an ectopic pregnancy, making answers A, B, and C incorrect.
After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? 1. hypoglycemia 2. jitteriness 3. resp depression 4. tachycardia
3. resp depression mag sulfate crosses the placenta and adverse neonatal effects are: resp depression hypotonia bradycardia the serum blood sugar isnt affected by mag sulfate the neonate wold be floppy, not jittery
