Pregnancy, Labor, Childbirth, Postpartum - At Risk (Level 1)
What is a risk for a hypertensive disorder of pregnancy?
A first pregnancy and obesity are both documented risk factors for hypertensive disorders of pregnancy. The risk for a hypertensive disorder of pregnancy increases when the client is younger than 20 years of age or older than 35 years of age.
A client with preeclampsia who is receiving an infusion of magnesium sulfate is showing signs of toxicity. What antidote should the nurse have available at the client's bedside? Calcium gluconate (Kalcinate) Edetate disodium (Disodium EDTA) Sodium polystyrene sulfonate (Kayexalate) HydrALAZINE hydrochloride (Apresoline)
Calcium gluconate (Kalcinate) Hypermagnesemia causes muscle depression; calcium gluconate (Kalcinate), the magnesium sulfate antidote, promotes muscle function. Edetate disodium (Disodium EDTA) is used in chelation therapy for lead poisoning. Sodium polystyrene sulfonate (Kayexalate) is used for hyperkalemia. HydrALAZINE hydrochloride (Apresoline) is an antihypertensive.
A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem? Two hard-boiled eggs ⅓ cup of red grapes ½ cup of red kidney beans 3 oz of skinless chicken breast
½ cup of red kidney beans One half cup of red kidney beans contains 2.6 mg of iron. This food contains the greatest amount of iron among the options offered. Two hard-boiled eggs contain 1.2 mg of iron. One third of a cup of red grapes contains 0.1 mg of iron. Three ounces of skinless chicken breast contains 0.9 mg of iron.
A health care provider prescribes an intravenous infusion of magnesium sulfate for a client with preeclampsia. What baseline assessment is essential before the nurse initiates the infusion?
Respiratory rate Magnesium sulfate toxicity depresses respiration; therefore it is essential to obtain a baseline respiratory rate before initiating therapy. The serum glucose level is unrelated to magnesium sulfate toxicity. Deviations in temperature do not indicate magnesium sulfate toxicity. A decreased level of consciousness may indicate worsening preeclampsia, not magnesium sulfate toxicity.
A nurse is caring for a client in labor whose fetus is in the breech presentation. For what complication should the nurse monitor the client? Hemorrhagic shock Increased blood pressure Compression of the cord Meconium in the amniotic fluid
Compression of the cord The cord may prolapse after the membranes rupture, and pressure of the presenting part on the cord could compress the cord, resulting in fetal hypoxia. The risk for hemorrhage or preeclampsia in a breech presentation is no greater than that in a cephalic presentation. Meconium in the amniotic fluid is expected because as the fetus's buttocks are compressed, meconium may be expelled.
What should be included in the nursing care for a client at 41 weeks' gestation who is to have a contraction stress test? Having the client empty her bladder Placing the client in a supine position Informing the client about the need for cesarean birth Preparing the client for insertion of an internal monitor
Having the client empty her bladder Once the test is begun the client will require continuous electronic monitoring and will be confined to bed; contractions are more uncomfortable with a full bladder. The client should be placed in the semi-Fowler position to help prevent supine hypotension. Informing the client about the need for cesarean birth is premature and may cause unnecessary anxiety; however, a cesarean birth may be necessary if the results of the test are positive. Only external monitoring is performed, because there is no indication that the membranes have ruptured.
What is Hyperemesis gravidarum?
A severe type of nausea/vomiting during pregnancy.
A woman in active labor arrives at the birthing unit. She tells the nurse that she was found to have a chlamydial infection the last time she visited the clinic but that she stopped taking the antibiotic after 3 days because she "felt better." What would the nurse anticipate as part of the plan of care, in light of this history? Administration of antibiotics before delivery Oxytocin (Pitocin) infusion to augment labor Epidural anesthesia to relieve difficult labor discomfort Magnesium sulfate infusion to prevent a precipitous birth
Administration of antibiotics before delivery A maternal chlamydia infection is transmitted to the newborn during passage through the birth canal; therefore administration of antibiotics before delivery is necessary. If birth is imminent, the safest method is cesarean birth. There is no reason to accelerate labor. Time is needed to prepare for a cesarean birth. A difficult labor is not related to a maternal chlamydial infection. A precipitous birth is not related to a maternal chlamydial infection.
A nurse is caring for a client with a history of treatment for preterm labor during this pregnancy. The client now is at 33 weeks' gestation. With regard to sexual intercourse, the nurse should explain that it is: Allowed if penile penetration is not deep Permitted unless there is vaginal discomfort Limited to once a week to decrease contractions Eliminated to prevent stimulation of uterine activity
Eliminated to prevent stimulation of uterine activity Prostaglandins in semen may stimulate labor, and penile contact with the cervix may increase myometrial contractility. Sexual intercourse may cause labor to progress.
A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at −2. For what complication should the nurse assess when caring for this client? Vaginal bleeding Urinary tract infection Prolapse of the umbilical cord Meconium in the amniotic fluid
Prolapse of the umbilical cord A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.
A client is admitted with a diagnosis of preeclampsia. What significant clinical finding does the nurse expect when reviewing the client's history? Proteinuria Tachycardia Increased serum glucose Tonic-clonic movements
Proteinuria A characteristic of preeclampsia is vasospasms that cause renal injury, resulting in loss of protein in the urine. The maternal heart rate is not affected by preeclampsia. An increased serum glucose level is associated with uncontrolled diabetes, not preeclampsia. There are no data to indicate that the client had or is having a seizure. The admitting diagnosis is preeclampsia, not eclampsia.
A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy? Shock Anxiety Infection Hyperoxygenation
Shock Hemorrhage can result from a ruptured tubal pregnancy and shock may ensue. Although the client may be very anxious, the signs and symptoms are those of hemorrhagic shock. There are no data, such as fever or a rising white blood cell count, to support the conclusion that the client has an infection. The data does not support a hyperoxygenated state.
A pregnant client comes to the emergency department because of vaginal bleeding. The nurse asks the client to estimate how heavy the bleeding is. What is the best gauge for the client to use? Number of clots that were passed Changes in fetal activity when bleeding Increased weakness since bleeding began Amount of blood lost in relation to usual menstrual flow
Amount of blood lost in relation to usual menstrual flow Determining the amount of blood lost in relation to her usual menstrual flow gives the client a familiar gauge with which to estimate the amount of bleeding she is experiencing. The presence of clots does not indicate the amount of bleeding. Changes in fetal activity may indicate a problem, but there is no relationship to the amount of bleeding. Weakness is a subjective symptom and may not reflect blood loss.
A client in the high-risk postpartum unit had a precipitous labor and birth. What maternal complication should the nurse anticipate? Hypertension Hypoglycemia Chilling and shivering Bleeding and infection
Bleeding and infection Precipitate birth is associated with an increased maternal morbidity rate because hemorrhage and infection may occur as a result of the trauma of a rapid, forceful birth in a contaminated field. Hypertension is anticipated in a client with preeclampsia. There are not enough data to indicate that this client has preeclampsia. A low blood glucose level is not expected after a precipitous birth. Chilling and shivering are common maternal responses after all types of births because of cardiovascular and vasomotor changes.
A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. What complication does the nurse suspect? Hydatidiform mole Vena cava syndrome Marginal placenta previa Complete abruptio placentae
Complete abruptio placentae Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20 percent effaced and 2 cm dilated, with her membranes intact and contractions 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be? Educating the client on what to expect during labor Discussing pain management options available during labor Discussing the possibility of using Pitocin to move labor along Contacting the health care provider about the need for a cesarean birth
Contacting the health care provider about the need for a cesarean birth Transmission of genital herpes simplex virus (HSV-2) to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the health care provider of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth as soon as possible.
A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client? Increased blood pressure and pulse Reduction of pain in the perineal area Gradual cervical dilation as labor progresses Decreased frequency and duration of contractions
Decreased frequency and duration of contractions Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.
A client with worsening preeclampsia is admitted to the high-risk unit, and the nurse manager places her in a private room. A nonstimulating environment is important for a client with increased cerebral irritability because it: Limits intracellular fluid reabsorption Reduces the severity of frontal headaches Decreases the probability of generalized seizures Prolongs the duration of action of hypotensive medications
Decreases the probability of generalized seizures Even minimal sensory stimuli can trigger exaggerated cerebral responses such as seizures; therefore a nonstimulating environment is therapeutic. Intracellular volume should be increased during pregnancy, so limiting the intracellular reabsorption would not be desirable. A nonstimulating environment does not reduce the severity of headaches resulting from hypertension. A nonstimulating environment has no relation to the duration of action of antihypertensive drugs.
What are -placenta previa -abruptio placentae .
Placenta previa - Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa. Abruptio placentae - Premature separation of a normally implanted placenta is known as abruptio placentae; it occurs because the placenta is attached insecurely to the uterine wall
A primigravida in whom placenta previa has already been diagnosed is admitted with bright-red vaginal bleeding at 34 weeks' gestation. What is the nurse's initial intervention? Ambulating the client to facilitate labor contractions Inserting an internal scalp electrode to assess fetal heart tones Performing a vaginal examination to determine progression of labor Positioning the client in the side-lying position to ease pressure on the cervix
Positioning the client in the side-lying position to ease pressure on the cervix The side-lying position reduces pressure on the cervical os and increases uterine perfusion. A client who is bleeding should not ambulate, because this may worsen the bleeding.The vaginal area should not be disturbed, because this may precipitate increased bleeding; an external monitor should be used.
What is the priority nursing intervention for a client with severe preeclampsia? Isolating her in a dark room Maintaining her in a supine position Encouraging her to drink clear fluids Protecting her against extraneous stimuli
Protecting her against extraneous stimuli Bedrest, a quiet room, and minimal stimulation are essential in reducing the risk of seizures. The client will need constant observation and should not be isolated. Maintaining her in a supine position may cause temporary supine hypotension and resultant fetal bradycardia; it also may result in aspiration if a seizure occurs. Fluid intake depends on the client's condition and the health care provider's prescriptions.
A nurse is assessing a client with worsening preeclampsia. What is the most significant clinical manifestation of severe preeclampsia? Polyuria Vaginal spotting Proteinuria of 3+ Blood pressure of 130/80 mm Hg
Proteinuria of 3+ As preeclampsia worsens, blood pressure and edema increase and degenerative changes of the kidney cause increasing proteinuria (3+). With worsening preeclampsia, oliguria, not polyuria, is expected. Vaginal spotting is not a sign of worsening preeclampsia. A blood pressure of 130/80 mm Hg is within acceptable limits; however, there is insufficient information to determine whether it is increased in this client.
What is the nursing action, during the postpartum period, that holds the highest priority for a client with class I heart disease? Promoting early ambulation Watching for signs of cardiac decompensation Assessing the mother's emotional reaction to the birth Instructing the mother about activity levels during the postpartum period
Watching for signs of cardiac decompensation Cardiac decompensation may occur because of the increased circulating blood volume during the early postpartum period, which requires increased cardiac function. Although promotion of early ambulation, assessing the mother's emotional reaction to the birth, and instructing the mother regarding activity during the postpartum period are all important, they are not the priority.