Recommended Maternal and Newborn Chapter 8: High-Risk Antepartum

2. Take the woman's blood pressure. The nurse should assess the client's blood pressure. Headache is a symptom of preeclampsia. Preeclampsia, a serious complication, is a hypertensive disease of pregnancy.

A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Assess the woman's fundal height. 4. Ask the woman about stressors at work.

1. Weight change from 128 pounds to 138 pounds. A weight gain of 10 pounds in a 4-week period is worrisome. The recommended weight gain during the second and third trimesters is approximately 1 pound per week. A weight gain above that which is recommended can be related to a few things, including preeclampsia, excessive food intake, or multiple gestations.

A 32-week-gestation client was last seen in the prenatal client at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm.

4. "If you follow your diet and exercise you will probably need no insulin." It is unlikely that this client will need any medication. Diet and exercise will probably control the diabetes.

A client has just been diagnosed with gestation diabetes. She cries, "Oh no! I will never be able to give myself shots!!" Which of the following responses by the nurse is appropriate at this time? 1. "I am sure you can learn for your baby." 2. "I will work with you until you feel comfortable giving yourself the insulin." 3. "We will be giving you pills for the diabetes." 4. "If you follow your diet and exercise you will probably need no insulin."

1. Grand mal seizure. Clients with severe preeclampsia are high risk for seizure.

A client with 4 protein and 4 reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

3. "The bacteria are living in your vagina. They will not hurt you but we will give you medicine in labor to protect your baby from getting sick." This answer is correct. Exposure to group B strep is very dangerous for neonates

A client, 37 weeks' gestation, has been advised that she is positive for group B streptococci. Which of the following comments by the nurse is appropriate at this time? 1. "The doctor will prescribe intravenous antibiotics for you. A visiting nurse will administer them to you in your home." 2. "You are very high risk for an intrauterine infection. It is very important for you to check your temperature every day." 3. "The bacteria are living in your vagina. They will not hurt you but we will give you medicine in labor to protect your baby from getting sick." 4. "This bacteria causes scarlet fever. If you notice that your tongue becomes very red and that you feel feverish you should call the doctor immediately."

2. Draw 5 units regular first and 15 units NPH second into the same syringe and inject.

A diabetic client is to receive 5 units regular and 15 units NPH insulin at 0800. In order to administer the medication appropriately, what should the nurse do? 1. Draw 5 units regular in one syringe and 15 units NPH in a second syringe and inject in different locations. 2. Draw 5 units regular first and 15 units NPH second into the same syringe and inject. 3. Draw 15 units NPH first and 5 units regular second into the same syringe and inject. 4. Mix 5 units regular and 15 units NPH in a vial before drawing the full 20 units into a syringe and inject.

2. Diet control with exercise. About 95% of gestational diabetic clients are managed with diet and exercise alone.

A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? 1. Oral hypoglycemic agents. 2. Diet control with exercise. 3. Regular insulin injections. 4. Inhaled insulin.

1. Assess deep tendon reflexes. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the preeclampsia. For example, if the reflexes are 2, the client would be much less likely to become eclamptic than a client who has 4 reflexes with clonus.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

3. Verify the identity of the woman. Although this is an important action that must be taken before the administration of any medication, it is especially critical in this situation.

A woman is to receive RhoGAM at 28 weeks' gestation. What action must the nurse take before giving the injection? 1. Validate that the baby is Rh negative. 2. Assess that the direct Coombs' test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

1. Weight loss. Weight loss is a positive sign. One of the side effects of preeclampsia is edema and weight gain.

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2 proteinuria. 3. Decrease in plasma protein. 4. 3 patellar reflexes.

1. G1P0000, age 44 with history of diabetes mellitus. This primigravid client—age 44 and with a history of diabetes—is very high risk for preeclampsia. Women who are highest risk for the disease are primigravidas, those with multiple gestations, women who are younger than 17 or older than 34, those who had preeclampsia with their first pregnancy, and women who have been diagnosed with a vascular disease like diabetes mellitus or chronic hypertension.

Which of the following clients is at highest risk for developing a hypertensive illness of pregnancy? 1. G1P0000, age 44 with history of diabetes mellitus. 2. G2P0101, age 27 with history of rheumatic fever. 3. G3P1102, age 25 with history of scoliosis. 4. G3P1011, age 20 with history of celiac disease.

3. Dark brown vaginal bleeding. The condition is usually diagnosed after a client complains of brown vaginal discharge early in the "pregnancy." No pain is associated with this condition.

Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatiform mole)? 1. Protracted pain. 2. Variable fetal heart decelerations. 3. Dark brown vaginal bleeding. 4. Suicidal ideations.