Chapter 11: high-risk perinatal care- existing conditions

Which opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes? A) Heroin B) Alcohol C) Phencyclidine palmitate (PCP) D) Cocaine

*A) Heroin* Rationale: The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. Alcohol is not an opiate. PCP is not an opiate. Cocaine is not an opiate.

The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function? A) Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics B) Prepare the woman for delivery by cesarean section since this is the recommended delivery method to sustain hemodynamics C) Encourage the woman to avoid the use of narcotics or epidural regional analgesia since this alters cardiac function D) Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling

*A) Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics* Rationale: The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor. A vaginal delivery is the preferred method of delivery for a woman with cardiac disease as it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

A nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function? A) Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics. B) Prepare the woman for delivery by cesarean section because this is the recommended delivery method to sustain hemodynamics. C) Encourage the woman to avoid the use of narcotics or epidural regional analgesia because this alters cardiac function. D) Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling.

*A) Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics.* Rationale: The side-lying position with the head and shoulders elevated helps facilitate hemodynamics during labor. A vaginal delivery is the preferred method for a woman with cardiac disease because it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. Epidural anesthesia for labor is preferred. (Easterling and Stout, 2012). Using the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.

A pregnant woman is being examined by the nurse in the outpatient obstetric clinic. The nurse suspects systemic lupus erythematosus (SLE) after revealing which symptoms? (Select all that apply.) A) Muscle aches B) Hyperactivity C) Weight changes D) Fever E) Hypotension

*A) Muscle aches* *C) Weight changes* *D) Fever* Rationale: Fatigue, rather than hyperactivity is a common sign of SLE. Hypotension is not a characteristic sign of SLE. Common symptoms, including myalgias, fatigue, weight change, and fevers, occur in nearly all women with SLE at some time during the course of the disease. Although a diagnosis of SLE is suspected based on clinical signs and symptoms, it is confirmed by laboratory testing that demonstrates the presence of circulating autoantibodies. As is the case with other autoimmune diseases, SLE is characterized by a series of exacerbations (flares) and remissions (Chin and Branch, 2012).

Thalassemia is a relatively common anemia in which: A) an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs). B) RBCs have a normal life span but are sickled in shape. C) folate deficiency occurs. D) there are inadequate levels of vitamin B12.

*A) an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs).* Rationale: Thalassemia is a hereditary disorder that involves the abnormal synthesis of the á or â chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs. This is the underlying description for sickle cell anemia. Folate deficiency is the most common cause of megaloblastic anemias during pregnancy. B12 deficiency must also be considered if the pregnant woman presents with anemia.

Hypothyroidism occurs in 2 to 3 pregnancies per 1000. Pregnant women with untreated hypothyroidism are at risk for: (Select all that apply.) A) miscarriage. B) macrosomia. C) gestational hypertension. D) placental abruption. E) stillbirth.

*A) miscarriage.* *C) gestational hypertension* *D) placental abruption.* *E) stillbirth.* Rationale: Hypothyroidism is often associated with both infertility and an increased risk of miscarriage. Infants born to mothers with hypothyroidism are more likely to be of low birth weight or preterm. These outcomes can be improved with early diagnosis and treatment. Pregnant women with hypothyroidism are more likely to experience both preeclampsia and gestational hypertension. Placental abruption and stillbirth are risks associated with hypothyroidism. Placental abruption and stillbirth are risks associated with hypothyroidism.

A pregnant woman in her first trimester with a history of epilepsy is transported to the hospital via ambulance after suffering a seizure in a restaurant. The nurse expects which health care provider orders to be included in the plan of care? (Select all that apply.) A) valproate (Depakote). B) Serum lab levels of medications. C) Abdominal ultrasounds. D) Prenatal vitamins with vitamin D. E) carbamazepine (Tegretol).

*B) Serum lab levels of medications.* *C) Abdominal ultrasounds.* *D) Prenatal vitamins with vitamin D.* Rationale: Carbamazepine (Tegretol) and valproate (Depakote) should be avoided if possible during pregnancy, especially during the first trimester, because their use is associated with NTDs in the fetus. Checking lab levels of medications, performing abdominal ultrasounds to assess fetal growth, and taking prenatal vitamins with vitamin D are all expected interventions for a pregnant woman diagnosed with epilepsy.

From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks: A) in the first trimester. B) between 24 to 36 weeks of gestation. C) during the last 4 weeks of pregnancy. D) immediately postpartum.

*B) between 24 to 36 weeks of gestation.* Rationale: Women often have few symptoms of asthma during the first trimester. The severity of symptoms peaks between 24 and 36 weeks of gestation. Asthma appears to be associated with intrauterine growth restriction and preterm birth. During the last 4 weeks of pregnancy symptoms often subside. The period between 24 and 36 weeks of pregnancy is associated with the greatest severity of symptoms. Issues have often resolved by the time the woman delivers.

A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often: A) orthopnea. B) decreasing energy levels. C) moist frequent cough and frothy sputum. D) crackles (rales) at the bases of the lungs on auscultation.

*B) decreasing energy levels.* Rationale: Orthopnea is a finding that appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. A moist, frequent cough appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema.

Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: A) with good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B) the most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C) infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D) at birth, the neonate of a diabetic mother is no longer at any greater risk.

*B) the most important cause of perinatal loss in diabetic pregnancy is congenital malformations.* Rationale: Even with good control, sudden and unexplained stillbirth remains a major concern. Congenital malformations account for 30% to 50% of perinatal deaths. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.

During pregnancy, alcohol withdrawal may be treated using: A) disulfiram (Antabuse). B) corticosteroids. C) benzodiazepines. D) aminophylline.

*C) benzodiazepines.* Rationale: Disulfiram is contraindicated in pregnancy because it is teratogenic. Corticosteroids are not used to treat alcohol withdrawal. Symptoms that occur during alcohol withdrawal can be managed with short-acting barbiturates or benzodiazepines. Aminophylline is not used to treat alcohol withdrawal.

Maternal and neonatal risks associated with gestational diabetes mellitus are: A) maternal premature rupture of membranes and neonatal sepsis. B) maternal hyperemesis and neonatal low birth weight. C) maternal preeclampsia and fetal macrosomia. D) maternal placenta previa and fetal prematurity.

*C) maternal preeclampsia and fetal macrosomia.* Rationale: Premature rupture of membranes and neonatal sepsis are not risks associated with gestational diabetes. Hyperemesis is not seen with gestational diabetes, nor is there an association with low birth weight of the infant. Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia. Placental previa and subsequent prematurity of the neonate are not risks associated with gestational diabetes.

During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: A) euglycemia. B) rheumatic fever. C) pneumonia. D) cardiac decompensation.

*D) cardiac decompensation.* Rationale: Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation. Symptoms of cardiac decompensation may appear abruptly or gradually.

In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: A) mother's age. B) number of years since diabetes was diagnosed. C) amount of insulin required prenatally. D) degree of glycemic control during pregnancy.

*D) degree of glycemic control during pregnancy.* Rationale: Although advanced maternal age may pose some health risks, for the woman with pregestational diabetes the most important factor remains the degree of glycemic control during pregnancy. The number of years since diagnosis is not as relevant to outcomes as the degree of glycemic control. The key to reducing risk in the pregestational diabetic woman is not the amount of insulin required but rather the level of glycemic control. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.

A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A) oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B) dietary modifications and insulin are both required for adequate treatment. C) glucose levels are monitored by testing urine 4r times a day and at bedtime. D) dietary management involves distributing nutrient requirements over three meals and two or three snacks.

*D) dietary management involves distributing nutrient requirements over three meals and two or three snacks.* Rationale: Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis.