ch 6 OB

16. A patient at 32 weeks' gestation is admitted to the high-risk OB unit with a diagnosis of preterm labor. On assessment the nurse finds the following: blood pressure, 182/96 mm Hg pulse, 106 beats/minute; respirations, 16 breaths/minute; regular uterine contractions of 5 in 10 minutes; and fetal heart rate of 145 beats/minute. The patient is dilated to 8 cm. Which action by the nurse is best? A. Administer the ordered dose of betamethasone (Celestone). B. Call for an immediate electrocardiogram (EKG). C. Document the findings and prepare for emergent delivery. D. Prepare to administer magnesium sulfate (Sulfamag).

; ANS: A Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 150 Heading: Vasa Previa Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. The administration of antenatal corticosteroids (betamethasone) is the most beneficial intervention for improvement of neonatal outcomes among people who give birth preterm. A single course of corticosteroids is recommended for pregnant people between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. B. Although the patient is mildly tachycardic, there is no need for an EKG without further information. C. There is no indication that delivery is imminent. D. Magnesium sulfate is a tocolytic drug used to stop labor, but it is contraindicated in women with advanced cervical dilation.

Insert UNF TB 06-01 here> Based on this image, what priority action should the nurse anticipate during labor for a patient who is 3 cm, 100% effaced, and 0 station with vaginal bleeding? A. Anticipate interventions for a prompt delivery. B. Type and screen for 2 units of blood. C. Prepare for labor augmentation with Pitocin. D. Monitor patient and repeat vaginal exam in 2 hours.

ANS: A

10. A nurse has admitted a patient with hyperemesis gravidarum and is reviewing the physician's orders. Which order should the nurse question? A. Betamethasone (Celestone) 100 mg IV every 8 hours B. Dimenhydrinate (Dramamine) 75 mg rectally every 4-6 hours C. Metoclopramide (Reglan) 10 mg IV every 8 hours D. Promethazine (Phenergan) 25 mg IV every 4 hours

ANS: A Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 149 Heading: Box 6-1 - Common Medications for Nausea and Vomiting of Pregnancy Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Medication; Critical Thinking Difficulty: Moderate Feedback A. Betamethasone is used to decrease the chance of respiratory distress syndrome in premature infants. It is given in two doses, 12 hours apart, at a dose of 12 mg. B. Dimenhydrinate is used to treat nausea and vomiting of pregnancy. C. Metoclopramide is used to treat nausea and vomiting of pregnancy. D. Promethazine is used to treat nausea and vomiting of pregnancy.

9. A nurse is assessing a patient in the perinatal clinic with diagnosed cervical insufficiency. The patient is in her 18th week of a viable pregnancy. Which action by the nurse is most appropriate? A. Assist with obtaining informed consent for a cerclage. B. Draw blood to assess the maternal Rh status. C. Facilitate a transvaginal and abdominal ultrasound. D. Refer the patient to a perinatal grief specialist.

ANS: A Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #2. Discuss the importance of complete and accurate documentation in caring for the patient experiencing an obstetric emergency. Page: 148-149 Heading: Cervical Insufficiency>Management Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Pregnancy; Communication Difficulty: Moderate Feedback A. Because the patient has diagnosed cervical insufficiency, a cerclage is appropriate therapy. This purse-string suture closes the cervix so the uterus can contain the pregnancy. It is usually removed in the 37th week to allow for vaginal delivery. Because it is an invasive procedure, informed consent is required. B. It is not necessary in this situation to draw blood to assess the maternal Rh status. C. It is not necessary in this situation to facilitate a transvaginal and abdominal ultrasound. D. It is not necessary in this situation to refer the patient to a perinatal grief specialist, although if the patient has unresolved grief following prior spontaneous abortions, a referral would be appropriate.

5. A patient in her second trimester of pregnancy presents to the perinatal clinic with complaints of scant vaginal bleeding, abdominal pain, and shoulder pain. What action should the nurse perform first? A. Assess her for a history of preterm labor. B. Obtain a blood sample for a b-hCG test. C. Prepare the patient for a pelvic exam. D. Request an order for methotrexate (Rheumatrex).

ANS: B Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 145 Heading: Ectopic Pregnancy Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Pregnancy; Assessment; Critical Thinking Difficulty: Difficult Feedback A. Preterm labor is not a risk factor for this patient. B. This patient is displaying symptoms of a possible ruptured ectopic pregnancy (vaginal bleeding, abdominal pain, shoulder pain). Shoulder pain can occur from nerve irritation due to the presence of blood in the pelvic cavity. A b-hCG test finding will be lower than expected for the gestational age. To facilitate a rapid diagnosis, the nurse should first obtain and send a blood sample for b-hCG test. C. The patient will most likely need a pelvic exam, but this is not the priority. D. Methotrexate is used for uncomplicated, non-life-threatening ectopic pregnancies. It would not be indicated in this patient because she has manifestations of rupture.

15. A patient who is 36 weeks pregnant presents to the perinatal clinic with complaints of backache, pelvic fullness, and uterine contractions. Which action by the nurse is most appropriate? A. Arrange admission to the hospital. B. Obtain a clean-catch, midstream urine sample. C. Obtain blood for a type and screen. D. Prepare to administer a tocolytic agent.

ANS: B Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 152 Heading: Preterm Labor Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. Arranging admission to the hospital is premature. B. Infection is a predisposing factor for preterm labor, so the nurse would be wise to collect a urine sample, which may be obtained via clean-catch or catheterized specimen. C. There is no indication that the patient will need blood imminently. D. Tocolytic agents to stop preterm labor are not used after the 34th week of gestation.

1. A patient presents to the perinatal clinic with abdominal pain. She has missed one period and, following a transvaginal ultrasound, pregnancy is confirmed. However, implantation has occurred in the right fallopian tube. The ectopic mass is 3 cm and has not ruptured. The nurse prepares the patient for which therapy? A. Laparoscopic salpingostomy B. Methotrexate C. Partial salpingectomy D. Salpingectomy by laparotomy

ANS: B Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 146 Heading: Management Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Application [Applying] Concept: Pregnancy; Assessment Difficulty: Moderate Feedback A. Laparoscopic salpingostomy would not be needed. B. Methotrexate, a chemotherapeutic drug and folic acid inhibitor that stops cell production and destroys remaining trophoblastic tissue, is used in the management of uncomplicated, non-life-threatening ectopic pregnancies. Patients are eligible for methotrexate therapy if the ectopic mass is unruptured and measures 4 cm or less on ultrasound examination. C. Partial salpingectomy would not be needed. D. Salpingectomy by laparotomy would not be needed.

14. A patient who is in her third trimester and is at risk for preterm birth calls the clinic to get the results of her fetal fibronectin test (fFN). The nurse sees the result is negative. Which advice to the patient is most appropriate? A. Come to the perinatal clinic for a screening ultrasound. B. Continue the current management plan as directed. C. Go to the hospital immediately for imminent delivery. D. Plan to continue taking betamethasone (Celestone) for 1 week.

ANS: B Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 152 Heading: Fetal Fibronectin Testing Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. There is no need for a screening ultrasound. B. A negative fFN test indicates that the chance of a patient giving birth in the next week is approximately 1%, so she should continue her management plan already in place. C. There is no need for hospitalization. D. Betamethasone is a corticosteroid shown to improve outcomes in premature birth. Because this patient is at low risk of delivery within the next week, betamethasone is not indicated.

7. A nurse is reviewing the chart of a 52-year-old primigravida patient who was admitted with moderate dark-brown vaginal bleeding. On physical exam, her uterus is large for dates. Which documentation in the chart would be most significant? A. Folic acid level. B. Ultrasound report. C. Documented fetal kick count. D. Pelvic culture results.

ANS: B Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #2. Discuss the importance of complete and accurate documentation in caring for the patient experiencing an obstetric emergency. Page: 146 Heading: Gestational Trophoblastic Disease Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Communication; Critical Thinking Difficulty: Difficult Feedback A. Folic acid level deficiencies are correlated with the occurrence of neural tube defects. There is no information provided that identifies that this is a concern. B. The incidence of gestational trophoblastic disease (GTD), including hydatidiform mole, increases in women of advanced age (especially over 50). Dark-brown vaginal bleeding is one symptom of this condition, and the nurse should be cognizant of its possibility. Because hydatidiform mole is diagnosed with ultrasound, the nurse should review the result. C. As molar pregnancies are associated with no fetus or one that is generally spontaneously aborted, fetal kick counts would not be noted. D. Based on the provided information, pelvic cultures would not be ordered for this patient.

19. A perinatal nurse is working with a patient who is diagnosed with hyperemesis gravidarum. The nurse should anticipate orders for which of the following treatments? Select all that apply. A! "Minimize protein intake to decrease nausea." B! "Crackers upon arising may alleviate nausea." C! "Ginger chews may be taken as a supplement." D! "Three main meals and avoid snacking." E! "Avoid foods that may act as sensory triggers."

ANS: B, C, E Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 149 Heading: Hyperemesis Gravidarum>Management Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. This is incorrect. High protein snacks are recommended as protein intake is critical during pregnancy. B. This is correct. This is a factual statement as crackers may help line the stomach and decrease stomach acid. C. This is correct. Ginger is a natural supplement which helps to decrease nausea. D. This is incorrect. Small frequent meals of dry, bland, high protein foods are recommended. E. This is correct. Certain foods can act as sensory triggers either upon ingestion or via odor. The patient when aware of these foods should avoid them.

18. A nurse is caring for a patient receiving magnesium sulfate for pre-eclampsia. Which findings indicate that the patient's clinical situation is deteriorating? Select all that apply. A! "FHR baseline variability is maintained." B! "Blood pressure is continuing to increase despite therapy." C! "Uterine contractions are becoming more irregular." D! "Patient states that her vision is becoming slightly blurred." E! "Adventitious lung sounds heard on auscultation."

ANS: B, D, E Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 157 Heading: Classification of Pre-eclampsia and Maternal and Fetal Morbidity and Mortality Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. This is incorrect. FHR baseline variability being maintained is a normal finding. B. This is correct. Treatment with magnesium sulfate should result in a decrease in maternal BP. Therefore, additional action may be needed to prevent progression of disease. C. This is incorrect. Treatment with magnesium sulfate acts on the smooth muscle and thereby decreases uterine contractions. This is an expected normal response to therapy. D. This is correct. Visual changes can indicate deteriorating CNS disturbances. This is a significant finding indicating worsening disease. E. This is correct. Adventitious lung sounds can correlate with pulmonary edema. This is a significant finding indicating worsening disease.

MULTIPLE RESPONSE 17. A nurse is teaching a patient the actions to take in the event the patient believes she is in preterm labor. Which of the following should the nurse include in the teaching plan? Select all that apply. A! "Come to the hospital immediately if you don't feel contractions." B! "Drink two to three glasses of a noncaffeinated beverage after emptying your bladder." C! "Feel for uterine contractions for the next 2 to 3 hours." D! "Lie down on your back with pillows under your knees." E! "Seek additional health care if you have four or more contractions in 1 hour."

ANS: B, E Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 154 Heading: Preventing Preterm Birth Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. This is incorrect. The absence of uterine contractions is not a reason to come to the hospital. B. This is correct. The nurse should instruct the patient to empty her bladder, drink two to three noncaffeinated beverages and feel for uterine contractions. The nurse should instruct the patient to either go to the hospital or call the health-care provider if she feels four or more contractions in 1 hour. C. This is incorrect. There is not enough information in this option as the nurse has not provided criteria for measurement to indicate whether there is a problem. D. This is incorrect. The nurse should instruct the patient to lie down on her side. E. This is correct. This is a factual statement.

13. A nurse has admitted a patient pregnant in her third trimester with moderate vaginal bleeding and severe abdominal pain. After assessing maternal vital signs, obtaining the fetal heart rate, and starting an IV-line, which action should the nurse do next? A. Administer betamethasone (Celestone) just prior to delivery. B. Discuss pros and cons of continuous fetal monitoring. C. Facilitate laboratory work, including blood type and screen. D. Obtain informed consent for emergent delivery.

ANS: C Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 150 Heading: Vasa Previa Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Critical Thinking Difficulty: Difficult Feedback A. Betamethasone is given if delivery is not imminent. B. Continuous electronic fetal monitoring is the standard of care, and although the nurse should educate the patient on its use, this discussion does not take priority. C. Women who present with third-trimester vaginal bleeding should be examined carefully for placenta previa or abruptio placentae. Bleeding accompanied by abdominal pain is the classic sign of placental abruption. Care includes obtaining maternal vital signs, assessing fetal heart rate, and starting an IV for fluid resuscitation or transfusion if needed. Blood work should be obtained for CBC, type and screen, coagulation studies, and a Kleihauer Betke determination. D. An emergent delivery is a possible (not certain) outcome, but obtaining consent does not take priority.

11. A pregnant patient in the second trimester is in the emergency department after a motor vehicle crash. She has a severe laceration of her arm resulting in a large blood loss. Which assessment should the nurse perform first? A. Blood pressure B. Fetal heart tones C. Pulse D. Respiratory rate

ANS: C Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 180 Heading: The Pregnant Patient Who Has Suffered Trauma Integrated Processes: Nursing Process: Assessment Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Pregnancy; Critical Thinking Difficulty: Moderate Feedback A. Because a woman's blood volume can increase dramatically during pregnancy, blood pressure is an unreliable indicator of a volume deficit. B. While fetal heart rate is an accurate indicator of volume deficit, this assessment is not the priority. C. Because a woman's blood volume can increase dramatically during pregnancy, blood pressure is an unreliable indicator of a volume deficit. Maternal pulse and fetal heart rate are much more accurate indicators. Because the priority in care of the pregnant trauma patient is care of the mother, the nurse should assess the mother's pulse first. D. Assessment of respiratory rate is not the priority.

8. A patient who recently had a miscarriage is in the clinic for follow-up. She sees the diagnosis "spontaneous abortion" on her chart and becomes visibly upset, stating, "I did not have an abortion!" Which response by the nurse is best? A. "Don't be upset that is just a medical term used commonly."B."I can come back and talk to you when you are not so upset."C."I see you are upset. Does it help to know this means miscarriage?"D."No one is accusing you of having an abortion."

ANS: C Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #2. Discuss the importance of complete and accurate documentation in caring for the patient experiencing an obstetric emergency. Page: 147 Heading: Spontaneous Abortions Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Pregnancy; Communication Difficulty: Moderate Feedback A. Telling the patient not to be upset is paternalistic and does nothing to educate her. B. Offering to come back later would be a useful option after the nurse has acknowledged the patient's feelings and discovered that she does not want to talk right now; otherwise, this statement might seem like rejection. C. The term "spontaneous abortion" is the medical term for miscarriage before 20 weeks' gestation. Medical terms are often confusing to laypeople, and it is the nurse's duty to inform patients of their meaning. Nurses should also be aware that the term "abortion" is politically and emotionally laden, so it should not be surprising that an uninformed layperson might become upset at its use. The nurse should acknowledge the patient's feelings and explain the term. D. Stating that no one is accusing the patient of having an abortion is defensive.

12. A nurse is teaching a patient pregnant in the second trimester who has been diagnosed with a partial placenta previa. Which information is most important to document? A. Patient and partner show no anxiety or helplessness and were given educational support material. B. Patient instructed that bleeding may occur as placenta totally covers the cervical os. C. Patient instructed to tell all health-care providers that vaginal exams are prohibited. D. Patient received information about placenta previa and understood it well.

ANS: C Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #2. Discuss the importance of complete and accurate documentation in caring for the patient experiencing an obstetric emergency. Page: 150 Heading: Placenta Previa Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Communication Difficulty: Moderate Feedback A. Assessing (and documenting) the psychosocial status of the patient and partner are important too, but safety takes priority. B. A partial placental previa only partly covers the cervical os. C. If the patient needs care from another health-care provider, she must tell them that, due to her placenta previa, all vaginal exams are prohibited. This is an important safety measure that must be taught and clearly documented. D. The statement that the patient received information and understood it well is vague and does not constitute an example of acceptable charting.

3. The perinatal nurse is caring for a patient at 26 weeks' gestation who has a history of hypertension that has been well controlled. Today she presents with a blood pressure of 156/102 mm Hg, and she has 2+ protein on urine dipstick. Which initial action by the nurse is most appropriate? A. Arrange admission to the high-risk OB unit. B. Instruct the patient on strict bedrest. C. Obtain a clean-catch urine sample. D. Prepare to administer IV antihypertensives.

ANS: C Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #3. Identify complications of pregnancy that require fetal and/or maternal surveillance. Page: 156 Heading: Pre-Eclampsia>Pathophysiology Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Assessment; Critical Thinking Difficulty: Difficult Feedback A. The patient does not need admission to the high-risk OB unit at this point. B. The patient does not need strict bedrest at this point. C. Pre-eclampsia can occur in a pregnant person who has chronic hypertension. This patient has the characteristics of hypertension after a period of good control and proteinuria of at least 2+ on dipstick (100 mg/dL). The nurse needs to ensure protein levels are assessed in two samples at least 4 hours apart and ensure the patient has no signs of a urinary tract infection, as protein can occur in a sample of infected urine. The nurse should obtain a clean-catch urine sample to send to the laboratory for analysis. Asymptomatic UTI can occur in up to 11% of pregnant people, so assessing for signs and symptoms may not be accurate. D. The patient does not need IV antihypertensives at this point.

6. A nurse is caring for a patient who has been diagnosed with an incomplete molar pregnancy. Which action by the nurse is most appropriate? A. Advise the patient that she can try to get pregnant in 3 months. B. Arrange a consultation with a radiation oncology nurse. C. Facilitate screening for systemic lupus erythematosus (SLE). D. Give the patient information on perinatal loss support groups.

ANS: D Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #1. Plan nursing assessments and interventions for the woman experiencing complications of pregnancy. Page: 146-147 Heading: Gestational Trophoblastic Disease Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Pregnancy Difficulty: Moderate Feedback A. Women should not become pregnant for at least a year afterward. B. Incomplete moles are almost always benign, so a consultation for a radiation oncology nurse is most likely not needed. C. Screening for SLE is done in patients who have habitual abortions. D. Gestational trophoblastic disease (GTD) is a disease characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters (instead of normal placental tissue) and a vast proliferation of trophoblastic tissue. GTD includes the diagnosis of hydatidiform mole ("molar pregnancy"). Complete moles have a proliferation of trophoblastic tissue but no fetal parts. An incomplete mole is associated with a coexistent fetus that is genetically abnormal and usually only survives a few weeks before being spontaneously aborted. Support groups for grieving parents are an important community resource, and the nurse should ensure that the patient has information on local organizations.

4. A 22-year-old patient presents to the emergency department with abdominal pain and vaginal bleeding. Her blood pressure is 90/58 mm Hg, her pulse is 120 beats/minute, and she complains of dizziness. Which action by the nurse takes priority? A. Assess the patient for sexually transmitted infections. B. Collect a urine sample for pregnancy testing. C. Obtain informed consent for a salpingectomy. D. Start two large-bore IVs for fluid replacement.

ANS: D Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #3. Identify complications of pregnancy that require fetal and/or maternal surveillance. Page: 145 Heading: Ectopic Pregnancy Integrated Processes: Nursing Process: Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Assessment; Critical Thinking Difficulty: Difficult Feedback A. Assessing for sexually transmitted infections is not a priority. B. Collecting a urine sample for pregnancy testing is not a priority. C. The nurse may need to obtain informed consent for an operative procedure once a definitive diagnosis is made, but this is not the priority. D. This patient has both signs (hypotension, tachycardia) and symptoms (complaints of dizziness) of acute volume loss. The priority is starting large-bore IV lines for fluid resuscitation.

2. The perinatal nurse is assessing a patient who is at 35 weeks' gestation in her first pregnancy. She is worried about having her baby "too soon," and she is experiencing uterine contractions every 10 to 15 minutes. The fetal heart rate is 136 beats/minute. A vaginal examination performed by the health-care provider reveals no cervical changes since her last examination. Ultrasound examination reveals the presence of V-shaped cervical funneling. Which action by the nurse is most appropriate? A. Educate the patient on benefits of corticosteroids. B. Facilitate admission to the high-risk OB unit. C. Prepare to administer a dose of magnesium sulfate. D. Reassure the patient that she is not in preterm labor.

ANS: D Chapter: Chapter 6 - Caring for the Woman Experiencing Complications During Pregnancy Objective: #3. Identify complications of pregnancy that require fetal and/or maternal surveillance. Page: 152 Heading: Preterm Labor Integrated Processes: Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Analysis [Analyzing] Concept: Pregnancy; Assessment; Critical Thinking Difficulty: Difficult Feedback A. The patient does not require corticosteroids. B. The patient does not require admission to the high-risk OB unit. C. The patient does not require magnesium sulfate. D. Preterm labor is defined as regular uterine contractions and cervical changes before the end of the 37th week of gestation. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor. Because this patient has no demonstrated cervical changes, she does not have the diagnosis. Also reassuring is the infrequency of her contractions; a defining characteristic of preterm labor is persistent uterine contractions (four every 20 minutes or eight per hour). Another reassuring finding is the presence of V-shaped cervical funneling; a change to U-shaped cervical funneling in a patient with a shortened cervix is associated with preterm labor in high-risk women with a prior spontaneous preterm birth.