Q-Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

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 young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?

Threatened abortion Explanation: Spontaneous abortion (miscarriage) occurs along a continuum: threatened, inevitable, incomplete, complete, missed. The definition of each category is related to whether or not the uterus is emptied, or for how long the products of conception are retained.

A client whose membranes have prematurely ruptured is admitted to the hospital. Which nursing intervention is a priority?

Routine monitoring of vital signs Explanation: Rupture of the membranes without the onset of labor places the woman at risk for infection. The priority is to monitor temperature routinely by the completion of vital signs. Antibiotic therapy is often initiated as well, depending upon closeness of labor initiation (naturally or induced). The fetus will be monitored on a regular basis and then continuously when the labor process occurs. Urine analysis and strict intake and output are not typically completed.

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume?

40% Explanation: Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock.

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 Explanation: 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.

A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

Amniocentesis Explanation: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.

A woman at 37 weeks' gestation presents to the labor and delivery area with symptoms of placental abruption (abruptio placentae). Which action should the nurse prioritize?

Ensure that large-bore IV access is obtained Explanation: A placental abruption (abruptio placentae) has distinct symptoms including vaginal bleeding with abdominal pain. The uterus is typically firm. The condition is an obstetrical emergency. The client should have IV excess established with a large-bore needle to enable the administration of blood and/or blood products. The client may be placed on either side if desired but it is not a priority and she should not be placed flat on her back. There is no need to dipstick urine for proteinuria. Maternal and fetal assessment are completed once symptoms are reported to the health care provider.

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?

Prevent maternal seizures Explanation: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

A nurse is providing care to a pregnant client hospitalized with preeclampsia. The nurse immediately notifies the health care provider that the client has developed eclampsia based on which finding?

seizure activity Explanation: Although a blood pressure greater than 160/110 mm Hg, hyperreflexia and proteinuria are associated with eclampsia. The onset of seizure activity identifies eclampsia.

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?

a client who had a myomectomy to remove fibroids Explanation: A previous myomectomy to remove fibroids can be associated with the cause of placenta previa. Risk factors also include maternal age greater than 30 years. A structurally defective cervix cannot be associated with the cause of placenta previa. However, it can be associated with the cause of cervical insufficiency. Alcohol ingestion is not a risk factor for developing placenta previa but is associated with placental abruption (abruptio placentae).

A pregnant client with multiple gestation arrives at the maternity clinic for a regular antenatal check up. The nurse would be aware that client is at risk for which perinatal complication?

congenital anomalies Explanation: Multiple gestation involves two or more fetuses. The perinatal complications associated with multiple pregnancy include preterm birth, maternal hypertension and congenital anomalies. Fetal nonimmune hydrops occurs in the infection of pregnant clients with parvovirus. Postterm birth, maternal hypotension, and fetal nonimmune hydrops are not seen as complications of multiple pregnancy.

A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?

gestational trophoblastic disease Explanation: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.

A woman in week 16 of her pregnancy calls her primary care provider's office to report that she has experienced abdominal cramping, vaginal spotting, and the passing of tissue. The nurse instructs the client to bring the passed tissue to the hospital with her. What is the correct rationale for this instruction?

to determine whether gestational trophoblastic disease is present Explanation: Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. This is why it is important for any woman who begins to miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of clear fluid-filled cysts changes the diagnosis from a simple miscarriage to gestational trophoblastic disease. The client is not instructed to bring in passed tissue to determine whether infection is present or the fetus is viable or to determine the stage of development of the fetus.

A client who is 8 weeks' pregnant comes to the emergency department reporting abdominal pain and spotting. The client also reports breast tenderness and fatigue. Additional assessment suggests a possible ectopic pregnancy and diagnostic evaluation is scheduled. The nurse would prepare the client for which test(s) to aid in confirming this diagnosis? Select all that apply.

transvaginal ultrasound beta-human chorionic gonadotropin (hCG) level Explanation: The use of transvaginal ultrasound to visualize the misplaced pregnancy and low levels of serum beta-hCG assist in diagnosing an ectopic pregnancy. The ultrasound determines whether the pregnancy is intrauterine, assesses the size of the uterus, and provides evidence of fetal viability. The visualization of an adnexal mass and the absence of an intrauterine gestational sac are diagnostic of ectopic pregnancy. In a normal intrauterine pregnancy, beta-hCG levels typically double every 2 to 4 days until peak values are reached 60 to 90 days after conception. Concentrations of hCG decrease after 10 to 11 weeks and reach a plateau at low levels by 100 to 130 days. Therefore, low beta-hCG levels are suggestive of an ectopic pregnancy. Urine for protein, platelet level, and complete blood count would provide no information about an ectopic pregnancy.

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: A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). 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. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

A nurse is providing discharge teaching for a pregnant client with preeclampsia who will be managed at home on bedrest. The nurse determines that the teaching was successful based on which client statement?

"I need to drink about 8 glasses of water a day." Explanation: A client with mild elevation in blood pressure may be placed on bed rest at home. The client is encouraged to rest as much as possible in the lateral recumbent position to improve uteroplacental blood flow, reduce blood pressure, and promote diuresis. The client will be asked to monitor her blood pressure daily (every 4 to 6 hours while awake) and report any increased readings; she will be counseled on taking daily fetal movement (kick) counts and report any decrease in fetal movements; and she will see her health care provider weekly for ongoing evaluations. The client should record daily fetal movement (kick) counts, and if there is any decrease in movement, she needs to be evaluated by her health care provider that day. A balanced, nutritional diet with no sodium restriction is advised. In addition, the client is encouraged to drink six to eight 8-oz glasses (1.5 to 2 liters) of water daily.

A pregnant client with preterm premature rupture of the membranes is being discharged home. A nurse is preparing the client's discharge teaching plan. Which instructions would the nurse include? Select all that apply.

"If you notice your belly starting to tighten, call your health care provider."' "Check your temperature each day, reporting any increase immediately." Explanation: Instructions should include monitoring the baby's activity by performing fetal movement (kick) counts daily; checking temperature daily and reporting any temperature increases to the health care provider; watching for signs related to the beginning of labor and reporting any tightening of the abdomen or contractions; avoiding any touching or manipulating of the breasts, which could stimulate labor; and taking showers for daily hygiene needs and avoiding sitting in a tub bath.

A client experiencing a threatened abortion is concerned about losing the pregnancy and asks what she can do to help save her baby. What is the most appropriate response from the nurse?

"Restrict your physical activity to moderate bed rest." Explanation: With a threatened abortion, moderate bedrest, light activities, and supportive care are recommended. Regular physical activity may increase the chances of miscarriage. Strict bedrest is not necessary and may hide additional bleeding as it pools in the vagina, only to begin again as the woman ambulates. Activity restrictions are part of standard medical management.

A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client?

Administer cryoprecipitate and platelets. Explanation: In a pregnant client with DIC, the nurse may be told to administer cryoprecipitate and platelets. Whole blood does not contain clotting factors. Therefore, a ratio of 4 units of blood to 1 unit of fresh frozen plasma, and not 1 unit of blood to 4 units of frozen plasma, should be considered. The nurse should aim at maintaining the client's hematocrit above 30% and not just 20%. The nurse should expect one unit of blood to increase the hematocrit by 1.5 g/dl (15 g/L) not 3g/dl (30 g/L).

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client?

Keep the suction equipment readily available. Explanation: The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect?

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

Which measure would the nurse include in the plan of care for a woman with prelabor rupture of membranes if her fetus's lungs are mature?

labor induction Explanation: With prelabor rupture of membranes (PROM) in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature.

A pregnant client with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse perform before administering a new dose?

patellar reflex Explanation: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration provides information to make an informed decision about administering the drug safely. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity.

During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition?

preeclampsia without severe features Explanation: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a tonic-clonic seizure or coma has occurred.

A pregnant client at 24 weeks' gestation arrives in the office and reports that her feet and legs are swelling. During a client evaluation, the nurse notes that she can elicit a 4-mm skin depression that disappears in 10 to 15 seconds. The client is considered at risk for preeclampsia. What additional assessment would be beneficial for the nurse to complete?

weight gain Explanation: Although edema is not a cardinal sign of preeclampsia, weight should be monitored frequently to identify sudden gains in a short time span. A urine culture is not indicated but urine would be checked for protein. A complete blood count may be done to evaluate the woman's status but would provide little information about the client's risk for preeclampsia. Fundal height is a routine assessment completed at each visit.

A pregnant 36-year-old client has presented to the emergency department with vaginal bleeding. While reviewing the client's history, the nurse suspects placenta previa when which risk factor(s) is found in the record? Select all that apply.

infertility treatment smoking advanced age for pregnancy previous induced abortion (medical abortion) Explanation: Research has identified certain risk factors for placenta previa. They include advanced age for pregnancy (35 years or older), previous cesarean birth, multiparity, uterine insult or injury, cocaine use, prior placenta previa, infertility treatment, Asian genetic background, multiple gestations, previous induced abortion (medical abortion), smoking, previous myomectomy to remove fibroids (leiomyomas), short interval between pregnancies, and hypertension or diabetes.

A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which description of dependent edema is most accurate?

Dependent edema may be seen in the sacral area if the client is on bed rest. Explanation: The nurse should know that dependent edema may be seen in the sacral area if the client is on bed rest. Pitting edema leaves a small depression or pit after finger pressure is applied to a swollen area and can be measured. Dependent edema may occur in clients who are both ambulatory and on bed rest.

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?

Dark red, "clumpy" vaginal discharge Explanation: Women with hydatidiform mole ("molar pregnancy") often pass blood clots or watery brown/dark red discharge from the vagina in the first trimester. If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.

What special interventions would the nurse implement in a client who is carrying twin fetuses?

Demonstrate to the client how to perform fetal movement (kick) counts after 32 weeks. Explanation: A woman carrying a multiple gestation needs to keep up with how her fetuses are doing, and an excellent way to do that is by doing fetal movement (kick) counts. This starts at around 32 weeks' gestation for an uncomplicated pregnancy and continues until birth. Weekly or biweekly NSTs begin after 32 weeks. Obstetrical ultrasounds are done every 4 to 6 weeks after confirmation of a multiple fetal pregnancy. The client needs to increase her intake, along with her iron and folic acid intake, to provide adequate nutrition for both fetuses.

A pregnant woman at 12 weeks' gestation comes to the office reporting she has begun minimal fresh vaginal spotting. She is distressed because her primary care provider indicates after examining her that they will "wait and see." Which response would be most appropriate from the nurse in answering this client's concerns?

Tell her that medication to prolong a 12-week pregnancy usually is not advised. Explanation: Because many early pregnancy losses occur as the result of chromosome abnormalities, an aggressive approach to prolong these is not usually recommended. It would not be appropriate for the nurse to suggest an over-the-counter tocolytic, nor to tell the client that the care provider meant something else such as maintaining strict bed rest. Advising the client to seek a second opinion would not change the end results.

A client has been admitted to the hospital with a diagnosis of preeclampsia with severe features. Which nursing intervention is the priority?

Confine the client to bed rest in a darkened room. Explanation: With preeclampsia with severe features, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures. The other interventions listed pertain to a client who has experienced a seizure and has thus progressed to eclampsia.

A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis?

LDH Explanation: HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a variant of the preeclampsia/eclampsia syndrome. The diagnosis is based on laboratory test results, including: low hematocrit, elevated LDH, elevated AST, elevated ALT, elevated BUN, elevated bilirubin level, elevated uric acid and creatinine levels, and low platelet count. White blood cell counts are not used to evaluate for HELLP.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin?

STIs Explanation: Indications for Rho(D) immune globulin include isoimmunization, ectopic pregnancy, chorionic villus sampling, amniocentesis, prenatal hemorrhage, molar pregnancy, maternal trauma, percutaneous umbilical sampling, therapeutic or spontaneous abortion, fetal death, or fetal surgery.

A woman is being admitted to the obstetric unit for severe preeclampsia. When assigning room placement, which area would be most appropriate?

at the end of the hallway Explanation: A sudden noise can trigger a seizure in a severely preeclamptic woman. Room placement, therefore, should not be near a high traffic area or noise, such as by a supply room, the staff elevator, or nurse's station.

A woman at 12 weeks' gestation comes to the clinic with vaginal bleeding. When assessing the woman further, 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. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion. Beta hCG is a hormone produced by trophoblast cells of the placenta, and its levels double every 29 to 53 hours during the first 30 days post implantation with a healthy, progressing pregnancy.

The nurse is orientating in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. Which symptoms would the preceptor describe to the new nurse as indicative of severe preeclampsia? Select all that apply.

Blood pressure above 160/110 mm Hg Nondependent edema Hyperactive deep tendon reflexes Explanation: Preeclampsia occurs when a pregnant woman develops hypertension occurring after 20 weeks' gestation and only resolves after the fetus is delivered. Preeclampsia is exhibited by 2+ or more proteinuria, nondependent edema, blood pressure greater than 140 mm Hg systolic and above 90 mm Hg diastolic, and CNS irritability demonstrated by hyperactive deep tendon reflexes. If the client has a seizure, she has moved to eclampsia. Glycosuria is not associated with preeclampsia.

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

Immediate surgery Explanation: The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.

The nurse is caring for a multigravid who experienced a placental abruption 4 hours ago. For which potential situation will the nurse prioritize assessment?

Uterine atony Explanation: A placental abruption (abruptio placentae) may occur any time before and during the labor process. After delivery, the woman who has had an abruption requires close monitoring for postpartum hemorrhage because of the risk for uterine atony. This does not cause increased blood pressure or blood incompatibilities.

A 28-year-old client and her current partner present for the first prenatal appointment with the ob/gyn. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize?

Assess client for anti-D antibodies. Explanation: The client should be checked for sensitization to Rh-positive blood. It is unknown if the client did have a miscarriage earlier, and if so, what the blood type was of the fetus. The risk is high for the current fetus to be affected with hemolytic disease, and this can be easily ruled out by assessing the mother for sensitization. If this screening is negative, then no further testing is required. If the father were Rh positive, then the mother be given Rho(D) immune globulin to prevent the woman from developing antibodies to the Rho(D) factor. However, if it is positive, the health care provider may order an amniocentesis to evaluate the fetus for hemolytic disease so proper treatment and monitoring may be given. It is too early to perform a direct Coombs test. It would be improper to ignore the potential of serious complications and simply continue with routine tasks and procedures at this time.

The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia, severe preeclampsia and eclampsia. The nurse suspects preeclampsia based on which finding?

BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation Explanation: Gestational hypertension is diagnosed when systolic blood pressure is over 140 mm Hg and/or diastolic pressure is over 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. Severe preeclampsia (i.e., preeclampsia with severe features) may develop suddenly or within days and bring with it high blood pressure of more than 160/110 mm Hg, cerebral and visual symptoms, and pulmonary edema.

The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?

Baby developing postbirth jaundice Explanation: The infant and mother have ABO incompatibility. The result is a development of antibodies and breaking down of the blood, resulting in jaundice in the infant after delivery. The mixing of some fetal blood with maternal blood during the amniocentesis would not cause placental abruption or preterm birth. Hemolytic anemia is caused by Rh incompatibility. ABO incompatibility will cause hemolytic disease.

A high-risk pregnant client is determined to have gestational hypertension. The nurse suspects that the client has developed preeclampsia with severe features based on which finding?

blurred vision Explanation: Visual symptoms such as blurred vision and blind spots suggest severe preeclampsia. Severe preeclampsia is characterized by a blood pressure of 160/110 mm Hg. Mild facial edema or hand edema occurs with mild preeclampsia. Proteinuria in severe preeclampsia is greater than 500 mg per 24 hours.

A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. On assessment, the nurse notes cool, clammy skin; confusion; and vital signs as the following: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize?

Rule out shock. Explanation: Any time a client presents with hemorrhage, the initial nursing consideration is assessment and evaluation of shock. The next step would be to treat the shock, which could include establishing IV access and providing the client with fluids. After the client is more stable, then the source of the bleeding would be determined. In this case, that would include performing a pregnancy test to determine if the client is pregnant to rule out a placenta complication. If it is determined that the client is pregnant, the fetus would be assessed, which could include using an EFM depending on the approximate age of the fetus.

The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. The nurse will stress the importance of frequent and continuous office visits to the client with:

a molar pregnancy. Explanation: Molar pregnancies can indicate the possibility of developing malignancy. The woman will need close observation and follow-up for a year, every 1 to 2 weeks for hCG levels to detect cancer. A follow-up visit after an ectopic pregnancy or a complete spontaneous abortion (miscarriage) are typically scheduled at 6 weeks, not monthly. A woman who is Rh negative does not need a follow-up visit because of her Rh status, but would be scheduled as per routine postpartum visits.

A 16-year-old client was at 12 weeks' gestation when she gave birth to a fetus last week. The client has come to the office for follow-up and, while waiting in an examination room, notices that on the schedule is written her name and "follow-up of spontaneous abortion." The client is upset about what is written on the schedule. How can the nurse best explain this terminology?

"Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy." Explanation: Abortion is a medical term for any interruption of a pregnancy before a fetus is viable, but it is better to speak of these early pregnancy losses as spontaneous abortions to avoid confusion with intentional terminations of pregnancies. The other responses are correct, but they do not provide the client with the most complete nor reassuring answer.

A 28-year-old primigravida client with type 2 diabetes comes to the health care clinic for a routine first trimester visit reporting frequent episodes of fasting blood glucose levels being lower than normal, but glucose levels after meals being higher than normal. What should the nurse point out that these episodes are most likely related to?

normal response to the pregnancy Explanation: This is a normal response to the pregnancy. During pregnancy, tissues become resistant to insulin to provide sufficient levels of glucose for the growing fetus. This can result in three normally occurring responses: blood glucose levels are lower than normal when fasting; blood glucose levels are higher than normal after meals; and insulin levels are increased after meals. The various hormones will prevent the mother from using most of the insulin produced to allow the extra glucose to get to the growing fetus.

The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize?

Sharp fundal pain and discomfort between contractions Explanation: A placental abruption (abruptio placentae) refers to premature separation of the placenta from the uterus. As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation. Painless vaginal bleeding and a fall in blood pressure are indicative of placenta previa. Pain in a lower quadrant and increased pulse rate are indicative of an ectopic pregnancy. Hypertension and oliguria are indicative of preeclampsia.

A client reports bright red, painless vaginal bleeding during at 32 weeks' gestation. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measure(s) should the nurse initiated? Select all that apply.

Determine the time the bleeding began and about how much blood has been lost. Obtain baseline vital signs and compare to those vital signs previously obtained. Attach external monitoring equipment to record fetal heart sounds and kick counts. Explanation: Assessment is a priority in the immediate care period. Determining the extent of the blood loss, obtaining vital signs and monitoring the fetus provides data. With the exception of performing a pelvic examination and placing the client in the supine position, all of the answers are appropriate immediate care measures. The nurse should never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix might tear the placenta further and initiate massive hemorrhage, which is possibly fatal to both client and fetus. The nurse should not place the client in the supine position for extended periods due to the possibility of supine hypotension. Left side lying position is suggested.

A nurse is providing care to a pregnant woman with preterm prelabor rupture of membranes (PPROM). On admission, the client's baseline information was as follows: temperature, 97.6°F (36.5°C); pulse, 76 beats/minute; fetal heart rate, 136 beats/minute; white blood cell count, 7 x 103cells/mm3 (7.0 x 109/L). Now, 8 hours later, assessment reveals the following: temperature, 99.6°F (37.7°C); pulse, 82 beats/minute; fetal heart rate, 180 beats/minute; white blood cell count, 8.5 x 103 cells/mm3 (8.5 X 109/L). The nurse suspects a possible infection based on the change in which parameter?

fetal heart rate Explanation: Nursing management for the woman with prelabor rupture of membranes (PROM) or preterm prelabor rupture of membranes (PPROM) focuses on preventing infection and identifying uterine contractions. The risk for infection is great because of the break in the amniotic fluid membrane and its proximity to vaginal bacteria. Therefore, maternal vital signs must be monitored closely. The nurse should be alert for a temperature elevation or an increase in pulse, which could indicate infection. Also the nurse will monitor the fetal heart rate continuously, reporting any fetal tachycardia (which could indicate a maternal infection). The nurse will evaluate the results of laboratory tests such as a complete blood count (CBC). An elevation in white blood cells would suggest infection. For this woman, the change in fetal heart rate is significant and suggests a possible infection. Although the temperature, pulse rate, and white blood cell count are slightly increased, they are still within acceptable limits. Concern would grow if the client's temperature increased above100.4°F (38°C), pulse rate rose significantly from baseline, or the white blood cell count rose above 10 x 103 cells/mm3 (10 x 109/L).

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect?

firm, rigid uterus on palpation Explanation: The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A nurse is reviewing the medical record of a pregnant client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition?

low-lying placenta Explanation: Placenta previa is currently classified with two terms: "placenta previa" and "low-lying placenta." If the placental edge is less than 2 cm from the internal os but does not cover it, the placenta is reported as low-lying. If the placental edge covers the internal os, it is labeled as a placenta previa. Placenta accreta spectrum includes three conditions. Accreta is the most common and is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle. Placenta increta occurs when the placenta invades the myometrium, and placenta percreta occurs when it has extended through the myometrium and uterine serosa and adjacent tissue.

The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions would the nurse most likely include? Select all that apply.

maintaining NPO status for the first day or two administering antiemetic agents obtaining baseline blood electrolyte levels monitoring intake and output Explanation: When hospitalization is necessary, oral food and fluids are withheld to allow the gut to rest. Antiemetic agents are ordered to help control nausea and vomiting. The woman is likely to be dehydrated, so the nurse would obtain baseline blood electrolyte levels and administer intravenous fluid and electrolyte replacement therapy as indicated. Once the nausea and vomiting subside, oral food and fluids are gradually reintroduced. Total parenteral nutrition or a feeding tube is used to prevent malnutrition only if the client does not improve with these interventions.

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.

The nurse is admitting a G3 P2 client at 38 weeks' gestation who arrived reporting painless bleeding from the vagina leading to the diagnosis of placenta previa. When questioned by the client as to what caused this, which most likely factor should the nurse point out in her answer?

previous cesarean birth Explanation: The risk of placenta previa is greatly increased when a woman has had a previous cesarean delivery due to the scarring of the endometrial lining. Maternal age over 35 years, and not just more than 30 years, is considered another risk factor. Placenta previa is more common among those living in high altitudes not among those living in coastal areas. Obesity is not recognized as a potential risk for this condition. Other risk factors can include uterine insult or injury, cocaine use, prior placenta previa, infertility treatment, multiple gestations, previous induced abortion (medical abortion), smoking, previous myomectomy to remove fibroids, short interval between pregnancies, hypertension, or diabetes.

A nursing instructor is conducting a session exploring the signs and symptoms of eclampsia to a group of student nurses. The instructor determines the session is successful after the students correctly choose which signs indicating eclampsia? Select all that apply.

proteinuria hyperreflexia blurring of vision Explanation: Eclampsia is usually preceded by an acute increase in blood pressure as well as worsening signs of multiorgan system failure seen as increasing liver enzymes, proteinuria, and symptoms such as blurred vision and hyperreflexia. Hyperglycemia and auditory hallucinations are not seen with an acute increase in maternal blood pressure or eclampsia.