Antepartum with Complications Quiz
Which clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding
Correct 3 Boardlike abdomen Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine. Which laboratory values are most important for the nurse to monitor in this client? 1. Cardiac enzymes 2. Serum electrolytes 3. Complete blood count (CBCs) 4. Human immunodeficiency virus (HIV) antibody levels
3. complete blood count (CBCs) Zidovudine can cause anemia, leukopenia, and granulocytopenia; these blood dyscrasias can be life threatening and therefore the CBC should be monitored. Cardiac enzymes are not affected directly by zidovudine. Serum electrolytes are not affected directly by zidovudine. Once infected, the client will continue to test positive for the antibody
Which statements are true regarding ectopic pregnancy? Select all that apply. 1 Smoking is one of the risk factors for ectopic pregnancy. 2 Ectopic pregnancy is directly related to fetopelvic incompatibility. 3 Ectopic pregnancy occurs when the fertilized egg implants in the fallopian tubes. 4 When a young women exhibits abdominal pain, ectopic pregnancy is suspected. 5 If the adolescent exhibits abdominal pain and hypotension, the ectopic pregnancy may have ruptured.
Correct 1 Smoking is one of the risk factors for ectopic pregnancy 3 Ectopic pregnancy occurs when the fertilized egg implants in the fallopian tubes 4 When a young women exhibits abdominal pain, ectopic pregnancy is suspected 5 If the adolescent exhibits abdominal pain and hypotension, the ectopic pregnancy may have ruptured
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? 1 Insulin needs will increase during the second trimester. 2 Insulin needs will decrease during the second trimester. 3 Insulin needs will not change during the second trimester. 4 Insulin will be switched to an oral antidiabetic medication during the second trimester.
Correct 1 Insulin needs to increase during the second trimester The second trimester of pregnancy exerts a diabetogenic effect on the maternal metabolic status. Major hormonal changes result in decreased tolerance of glucose, increased insulin resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. Increasing levels of human chorionic somatomammotropin, estrogen, progesterone, prolactin, cortisol, and insulinase increase insulin resistance through their actions as insulin antagonists. Insulin resistance is a glucose-sparing mechanism that ensures an abundant supply of glucose for the fetus. Maternal insulin requirements gradually increase from about 18 to 24 weeks of gestation to about 36 weeks' gestation. The use of oral antidiabetes agents is currently not recommended by the American Diabetes Association for use during pregnancy.
A client at 28 weeks' gestation is scheduled for a sonogram. The results reveal a small-for-gestational age fetus and a low-lying placenta. Which complication should the nurse assess this client for during the last trimester of pregnancy? 1 Preterm labor 2 Placenta previa 3 Premature separation of the placenta 4 Premature rupture of the membranes
Correct 2 Placenta previa Placenta previa is defined as an abnormally implanted placenta in the thin lower-uterine segment (i.e., low-lying, partially covering, or completely covering the cervical os). Preterm labor may occur at any time; it is not specific to a low-lying placenta. Premature separation of the placenta may occur with a normally implanted placenta. Premature rupture of the membranes may occur at any time, with or without a low-lying placenta.
The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of most concern to the nurse? 1 Continued bloody show 2 Cervical dilation of 4 cm 3 Contractions every 4 minutes 4 Spontaneous rupture of membranes 3 hours ago
Correct 4 Spontaneous rupture of membranes 3 hours ago Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus. GBS infection is a leading cause of neonatal morbidity and mortality. Continued bloody show, cervical dilation of 4 cm, and contractions every 4 minutes are all normal findings for a client in labor.
A client is found to have gestational hypertension in the twenty-second week of gestation. Which major complication of hypertensive disease associated with pregnancy should the nurse anticipate? 1 Placenta previa 2 Polyhydramnios 3 Isoimmunization 4 Abruptio placentae
Correct 4 Abruptio placentae Vasospasms of placental vessels occur because of increased blood pressure. As a result the placenta may separate prematurely (abruptio placentae). Placenta previa is an abnormal placental implantation and is not related to hypertension. Polyhydramnios, an excessive amount of amniotic fluid, is not associated with hypertensive disorders of pregnancy. Isoimmunization in pregnancy is associated with Rh incompatibility, not hypertension.
Which is a sign of a ruptured ectopic pregnancy in an adolescent? 1 Labor pains 2 Abdominal pain and bleeding 3 Abdominal pain and hypotension 4 Abdominal pain and hypertension
Correct 3 Abdominal pain and hypotension An ectopic pregnancy occurs when a fertilized egg implants outside the uterus. Hypotension and abdominal pain indicates that the ectopic pregnancy might have ruptured. Ectopic pregnancy cannot be diagnosed by normal labor pains. Ectopic pregnancy is ruled out if abdominal pain is associated with bleeding or hypertension.
What is the optimal method for the nurse to use to assess blood loss in a client with placenta previa? 1. count or weigh perineal pads 2. monitor pulse and blood pressure 3. check hemoglobin and hematocrit values 4. measure or estimate the height of the fundus
1. count or weigh perineal pads An accurate measurement of the amount of blood loss may be obtained by counting or weighing perineal pads. The vital signs will reflect the effects of the blood loss rather than the amount. Laboratory results demonstrate the effects of the blood loss rather than the amount. The fundus may be higher than expected, because the low-lying placenta prevents the descent of the fetus into the pelvis, but the height cannot be used to estimate blood loss.
A client at 36 weeks' gestation is admitted to the high-risk unit with heavy bleeding because of complete placenta previa. Why does the nurse place the client in a lateral Trendelenburg position? 1. to prevent shock 2. to control bleeding 3. to keep pressure off the cervix 4. to move the placenta off the cervix
1. to prevent shock The Trendelenburg position shunts blood to the upper body and vital organs. The Trendelenburg position will not help control the bleeding. Pressure on the cervix is thought to have no bearing on bleeding episodes. In late pregnancy the placenta does not change its location in the uterus. Also, the Trendelenburg position cannot move the placenta from the cervix.
After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response? 1. "it's premature separation of a normal implanted placenta." 2. "Your placenta isn't implanted securely in place on the uterine wall." 3. "You have premature aging of a placenta that is implanted in your uterine fundus." 4. "The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."
4. "the placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening." Implantation of the placenta in the lower uterine segment is the accepted definition of placenta previa. Premature separation of a normally implanted placenta is known as abruptio placentae; it occurs because the placenta is attached insecurely to the uterine wall. Premature aging of a placenta may not lead to placenta previa but will put the fetus in jeopardy.
A client is admitted with a diagnosis of preeclampsia. Which significant clinical finding does the nurse expect when reviewing the client's history? 1 Proteinuria 2 Tachycardia 3 Increased serum glucose 4 Tonic-clonic movements
Correct 1 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 at term is admitted in active labor. She has tested positive for human immunodeficiency virus (HIV). Which intervention in the standard prescriptions should the nurse question? 1 Sonogram 2 Nonstress test 3 Sterile vaginal examination 4 Internal fetal scalp electrode
Correct4 Internal fetal scalp electrode The electrode used for internal fetal monitoring pierces the fetal scalp; fetal exposure to maternal blood increases the risk of the fetus contracting HIV. Sonograms and nonstress tests are noninvasive tests that pose no risk to the fetus. Sterile vaginal examination is necessary to determine progression of labor; although invasive, it poses no risk to the fetus if standard precautions are used.
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min
Correct 1 Monitoring deep tendon reflexes 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider.
A nurse is teaching a health class about human immunodeficiency virus (HIV). Which basic methods are used to reduce the incidence of HIV transmission? Select all that apply. 1 Using condoms 2 Using separate toilets 3 Practicing sexual abstinence 4 Preventing direct casual contacts 5 Sterilizing the household utensils
Correct 1 Using condoms 3 Practicing sexual abstinence HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. Therefore a client should use condoms to prevent contact between the vaginal mucus membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.
A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Visual disturbances
Correct 1 Headache 3 Abdominal pain 5 Visual disturbances Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia.
A client with abruptio placentae has an emergency cesarean birth. Subsequently the nurse notes bloody urine in the indwelling catheter collection bag. Which impending problem does the nurse suspect? 1 Incisional nick in the bladder 2 Urinary infection from the catheter 3 Uterine relaxation with increased lochia 4 Disseminated intravascular coagulopathy
Correct 1 Incisional nick in the bladder During an emergency cesarean birth the urinary bladder may be nicked during attempts to reach the uterus. Bleeding associated with a urinary tract infection is unlikely to develop so soon after a birth. Lochia is expelled from the vagina, not the bladder. With dissociated intravascular coagulopathy there would be bleeding from other sites, such as the incision and the venipuncture site, not just the bladder.
Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia
Correct 1 Oropharyngeal candidiasis Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is the more common in a client infected with AIDs. It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat.
The nurse instructs a multipara who has just given birth to a large-for-gestational-age (LGA) infant how best to maintain a contracted uterus. Which statement indicates to the nurse that the teaching was effective? 1 "If I start to bleed, I'll call for help." 2 "I'll massage my uterus regularly to keep it firm." 3 "If I urinate frequently, my uterus will stay contracted." 4 "I'll call you every 15 minutes to massage my uterus."
Correct 2 "I'll massage my uterus regularly to keep it firm." The uterus responds rapidly to touch, and the mother may be involved in her own care. The uterus must be massaged before there are signs of bleeding. Although frequent urination may be beneficial, the client should be taught to massage the uterus to cause it to contract. Stating that she will call every 15 minutes to have her uterus massaged does not actively involve the mother in her own care and could be unsafe if the uterus becomes boggy during the 15-minute intervals.
An HIV-infected pregnant adolescent does not want a cesarean birth. Which finding would indicate the increased risk of perinatal transmission via vaginal birth? 1 A viral load of 800 copies/mL 2 A viral load of 1,200 copies/mL 3 Ruptured membranes and rapidly progressing labor 4 History of receiving combination antiretroviral therapy and having a viral load less than 400 copies/mL
Correct 2 A viral load of 1,200 copies/mL A vaginal birth in the case of a woman with a viral load of more than 1,000 copies/mL (1,200 copies/mL) has a high chance of perinatal transmission, so cesarean birth is the preferred method. A viral load less than 1,000 copies/mL (800 copies/mL) is not threatening and lessens the chances of perinatal transmission via vaginal birth. Women with ruptured membranes have to take intravenous zidovudine injection and may proceed for vaginal birth. Women undergoing antiretroviral therapy with viral loads of less than 400 copies/mL can opt for vaginal birth.
The nurse is performing a physical assessment of a pregnant woman. Which factor in the client's history increases the risk for abruptio placentae? 1 Hydramnios 2 Hypertension 3 Cardiac disease 4 Diabetes mellitus
Correct 2 Hypertension Abruptio placentae occurs in about 1% of all pregnancies. The problem is more common in women with hypertension; however the causative factors are not clear. Hydramnios occurs about 10 times more often in pregnancies involving clients with type 1 diabetes. Spontaneous abortion, preterm labor and birth, and intrauterine fetal growth retardation are more common in pregnant clients with heart disease than in those without it. There is not a higher incidence of abruptio placentae in clients with diabetes mellitus; clients with diabetes are more likely to experience preeclampsia or to go into preterm labor if they have diabetes before becoming pregnant, especially if pathologic changes related to diabetes are present.
A client with severe preeclampsia is receiving magnesium sulfate therapy. What is the priority nursing assessment as the nurse monitors this client's response to therapy? 1 Urine output 2 Respiratory rate 3 Deep tendon reflexes 4 Level of consciousness
Correct 2 Respiratory rate Respiratory depression occurs with toxic levels of magnesium sulfate; calcium gluconate should be readily available to counteract toxicity. Although the other assessments (urine output, deep tendon reflexes, and level of consciousness) are important, none is the priority.
Which gestational period is appropriate for the administration of corticosteroids during preterm labor? 1 Less than 20 weeks 2 20 to 24 weeks 3 24 to 34 weeks 4 More than 34 weeks
Correct 3 24 to 34 weeks If preterm labor occurs during 24 to 34 weeks of gestation and if labor is unavoidable, corticosteroids should be administered to promote lung maturity. Labors occurring before 20 weeks of gestation usually results in a nonviable fetus; corticosteroids would not need to be administered. Corticosteroids do not promote lung maturation during 20 to 24 weeks of gestation. Fetal lungs mature at 34 weeks of gestation. A fetus in this period of gestation would not require the administration of corticosteroids if labor is unavoidable.
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? 1 Call the client's mother and request a verbal consent. 2 Proceed with the preparation and forgo written consent. 3 Have the surgeon and attending primary healthcare provider sign the consent form. 4 Sign the consent form and have the nurse manager countersign the form.
Correct 3 Have the surgeon and attending primary healthcare provider sign the consent form. The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first
A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered? 1 It acts as a diuretic. 2 It has a sedative effect. 3 It acts as an anticonvulsant. 4 It has an antihypertensive effect.
Correct 3 It acts as an anticonvulsant The target tissue of magnesium sulfate is the myoneural junction; it decreases secretion of acetylcholine, thereby depressing neuromuscular transmission, which prevents seizures. Although diuresis occurs, this is not the purpose of giving magnesium sulfate. Magnesium sulfate does not have a sedative effect. It has a minimum hypotensive effect.
What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia? 1 Limiting IV fluid intake 2 Preparing for a possible precipitous birth 3 Maintaining a quiet, darkened environment 4 Obtaining magnesium gluconate as an antagonist
Correct 3 Maintaining a quiet, darkened environment A quiet, darkened room reduces stimuli, which is essential for limiting or preventing seizures. IV infusions are not limited. Infusions are monitored closely and usually maintained at a volume of 125 mL/hr. Precipitous birth is not a usual side effect of magnesium therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be kept on hand in case signs of toxicity appear.
Which intervention would reduce the risk of perinatal transmission via vaginal birth in an adolescent who is diagnosed with HIV infection? 1 Using forceps during delivery 2 Using a fetal scalp electrode during delivery 3 Using antiretroviral during the intrapartum period 4 Administering zidovudine an hour before labor
Correct 3 Using antiretroviral during the intrapartum period In the intrapartum period, antiretroviral therapy is recommended to prevent transmission of HIV. Therefore the risk of perinatal transmission may be reduced in an adolescent who receives antiretroviral therapy in the intrapartum period. Use of forceps or fetal scalp electrode during delivery may result in inoculation of the virus into the fetus; therefore, this should be avoided. Intravenous zidovudine should be given during labor, not an hour before it, if the adolescent is having a vaginal birth.
A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about 3 months ago and had to have her fallopian tube removed. The nurse determines that this young woman needs additional information when she makes which statement? 1 "Pelvic infections can cause this to happen." 2 "This kind of thing could happen to my sister again." 3 "I guess I'll have to wait a while to become an aunt." 4 "My sister is lucky, because she won't have a period again."
Correct 4 "My sister is lucky, because she won't have a period again." Removing a fallopian tube will not halt menses; endometrial proliferation and shedding will occur as long as the ovaries and uterus are present. Pelvic infections may lead to constriction of the fallopian tubes, after which a fertilized ovum may become trapped. There is evidence that an individual who has had one tubal pregnancy has a high probability of having another. Pregnancy should be delayed 6 to 12 months after a tubal pregnancy.
A pregnant client has a positive group B Streptococcus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan? 1 "Go straight to the outpatient area of the maternity unit for a nonstress test." 2 "You'll need to schedule visits twice a week with your healthcare provider until you deliver." 3 "Your baby will have to spend at least 3 days in the neonatal intensive care unit because of this infection." 4 "This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding."
Correct 4 "This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding." A client who has a positive result on GBS screening will need to be treated with an intravenous antibiotic, often penicillin or ampicillin, throughout the labor process to prevent transmission of the infection to the neonate. Vertical transfer of GBS to the neonate during labor is associated with higher rates of neonatal morbidity and mortality. Untreated, the risk to the neonate is high, and with transmission, the infant will need to be cared for in the neonatal intensive care unit. There is no need for an increase in the frequency of prenatal visits or nonstress testing as a result of a positive GBS finding.
A client with severe preeclampsia who was admitted to the high-risk unit anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? 1 "There's no way of telling at this time what the outcome will be." 2 "If you do what the primary healthcare provider tells you to do, everything will progress normally." 3 "The baby will probably be all right. Did you know that the amniotic fluid provides protection?" 4 "We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?"
Correct 4 "We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?" Explaining to the client that the fetus will be closely monitored and asking whether she would like to hear the heartbeat serves to reassure the client of the fetus's well-being. Stating that there is no way of telling at this time what the outcome will be does not provide the mother with reassurance regarding the fetus's status or whether anything is being done to monitor the fetus. Stating that if the client does what the primary healthcare provider tells her to do everything will progress normally provides false reassurance; following instructions does not guarantee a healthy newborn. Stating that the baby will be all right provides false reassurance, and amniotic fluid makes the umbilical cord less vulnerable but does not protect against other causes of fetal compromise.
A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows fetal bradycardia, and a change is seen in the contour of the client's abdomen. What is the nurse's priority intervention? 1 Checking the client's vital signs 2 Placing the client on her left side 3 Immediately placing an internal scalp electrode on the fetus 4 Alerting others regarding the need for immediate cesarean delivery
Correct 4 Alerting others regarding the need for immediate cesarean delivery Another nurse should be asked to notify the operating room staff, primary healthcare provider, anesthesiologist, and neonatal team to prepare. The client's nurse should monitor vital signs, watch for signs of hypotension and tachycardia, insert an indwelling catheter, and stay as calm as possible while explaining to the client that the staff are working together to bring about a safe outcome. The client is exhibiting signs of uterine rupture. An emergency cesarean birth is the priority. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the primary healthcare provider. Client history, fetal bradycardia, and change of abdominal contour indicate uterine rupture.
A client in the prenatal clinic is diagnosed with preeclampsia. Which clinical findings support this diagnosis? 1 Increased blood pressure of 150/100 mm Hg 2 Increased blood pressure that is accompanied by a headache 3 Blood pressure above the baseline that fluctuates with each reading 4 Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria
Correct 4 Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria A blood pressure higher than 140 mm Hg systolic and 90 mm Hg diastolic along with proteinuria is diagnostic of preeclampsia; assessments should be performed twice, 4 to 6 hours apart. Hypertension alone does not support a diagnosis of preeclampsia. Hypertension accompanied by a headache is not necessarily indicative of preeclampsia. Blood pressure above the baseline and fluctuating with each reading may occur at any time, not specifically in a client with gestational hypertension.
A nurse is caring for a client who was admitted with the diagnosis of severe preeclampsia and is now receiving an intravenous infusion of magnesium sulfate. What is the classification of this medication? 1 Diuretic 2 Oxytocic 3 Antihypertensive agent 4 Central nervous system depressant
Correct 4 Central nervous system depressant Magnesium sulfate is a central nervous system depressant; it eases cerebral irritability, thus preventing seizures. Magnesium sulfate is not a diuretic; however, adequate kidney function is necessary to promote its excretion, otherwise toxicity will result. Magnesium sulfate is not an oxytocic; oxytocin is used to promote uterine contractions and can cause an increased blood pressure. Magnesium sulfate is not an antihypertensive; however, it may cause a transient decrease in blood pressure because of its peripheral dilating effect.
While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? 1 Reveals her level of consciousness 2 Reveals the mobility of the extremities 3 Reveals the response to painful stimuli 4 Identifies the potential for respiratory depression
Correct 4 Identifies the potential for respiratory depression Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL. Deep tendon reflexes do not reveal a client's level of consciousness, mobility of the extremities, or the response to painful stimuli. Deep tendon reflexes can be associated with muscle strengthening.
A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which effect alerts the nurse to notify the primary healthcare provider? 1 Respiratory rate of 18 breaths/min 2 2+ patellar reflex response 3 Blood pressure of 112/76 mm Hg 4 Urine output of less than 100 mL in 4 hours
Correct 4 Urine output of less than 100 mL in 4 hours A decreased urine output of less than 25 mL/hr may be indicative of kidney damage, a result of the preeclampsia, and impending renal failure. Magnesium sulfate is excreted by the kidneys, and magnesium toxicity may occur. Respirations at this rate are within the expected range; a rate of at least 16 breaths/min should be present before each dose of magnesium sulfate. Loss of the patellar reflex is suggestive of magnesium sulfate toxicity; a 2+ reflex is within the expected range. A blood pressure of 112/76 mm Hg is within normal limits.
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does this indicate to the nurse regarding the condition of the placenta? 1 Infarcted 2 Low-lying 3 Immaturely developed 4 Separating prematurely
Correct2 Low-lying Implantation should occur in the upper third of the uterus; a low-lying placenta is termed placenta previa. Infarctions may appear on a placenta because of some interference with the blood supply; this is not related to its location within the uterus. Placenta previa indicates where the placenta is implanted and has no relationship to placental aging. Abruptio placentae, not placenta previa, is the premature separation of a normally implanted placenta.
Placenta previa is diagnosed when a client at 24 weeks' gestation presents with painless vaginal bleeding. The client is concerned that she has done something to cause the bleeding. How should the nurse respond? 1. "It's not your fault; these things happen." 2. "Don't worry; it's just a sign that labor is beginning." 3. "Your uterus may be weak—that's what causes the vaginal bleeding." 4. "You have a low-lying placenta that separates when the cervix dilates."
Correct4 "You have a low-lying placenta that separates when the cervix dilates." Presenting facts helps reduce feelings of guilt. Stating that the bleeding is not the client's fault is an inadequate explanation that does not offer any information. Labor may not be starting at this time. Placenta previa can occur in a woman with a healthy uterus.
A client at 30-weeks' gestation is admitted to the hospital with a diagnosis of low-lying placenta previa with slight vaginal bleeding. The client is stabilized and bleeding ceases. What is the nurse's primary focus when providing discharge teaching about care at home for this client? 1. Stay on strict bed rest and use a bedpan. 2. Maintain a calm and quiet environment. 3. Check fetal status with a stethoscope daily. 4. Avoid anything that may stimulate the cervix or uterus
Correct4 Avoid anything that may stimulate the cervix or uterus Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided. A calm, quiet environment is desired for all clients, not just those with placenta previa. Fetal status is assessed during prenatal visits, which generally are scheduled twice a week. Ultrasonographic examinations may be performed every two weeks, and fetal surveillance, including biophysical profiles and nonstress testing, are done during twice-weekly visits. If bleeding is under control and the client is stable, bathroom privileges and sitting in a chair for about an hour daily are allowed.
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
Correct4 Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? 1 Cerebral hemorrhage 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock
Correct4 Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A grand multipara at 34 weeks' gestation is brought to the emergency department because of vaginal bleeding. The nurse suspects that the client has a placenta previa. Which characteristic typical of placenta previa supports the nurse's conclusion? 1 Painful vaginal bleeding in the first trimester 2 Painful vaginal bleeding in the third trimester 3 Painless vaginal bleeding in the first trimester 4 Painless vaginal bleeding in the third trimester
Correct4 Painless vaginal bleeding in the third trimester As the lower uterine segment stretches and thins, painless tearing and bleeding occur at the low implantation site. First-trimester bleeding, painful or painless, is associated with spontaneous abortion or inadequate implantation, not placenta previa. Painful vaginal bleeding in the third trimester is usually associated with abruptio placentae rather than placenta previa.
