Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications
A nurse is caring for a 25-year-old G1P0 at 37 weeks' gestation. The client's history indicates that the client has had alcohol abuse disorder throughout their pregnancy. What signs and symptoms does the nurse expect the newborn to exhibit? Drag words from the choices below to fill in each blank in the following sentence. The nurse recognizes the newborn is exhibiting signs and symptoms of fetal alcohol syndrome, which include , , , and .
jitteriness, thin upper lip, large, narrow-spaced eyes, and flat midface
What would be the physiologic basis for a placenta previa?
low placental implantation Explanation: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.
A pregnant client is diagnosed with preeclampsia and is to receive medication therapy to prevent eclampsia. Which medication does the nurse anticipate being prescribed?
magnesium sulfate Explanation: Magnesium sulfate remains the drug of choice to prevent eclampsia despite other drugs being used, such as hydralazine, labetalol, or nifedipine.
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
The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education?
signs of preterm labor
A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best?
"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications."
A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that:
as long as she receives Rho(D) immune globulin, there is no limit. Explanation: Because Rho(D) immune globulin supplies passive antibodies, it prevents the woman from forming antibodies. Without antibodies that could affect the fetus, the woman could have as many children as she wants.
A pregnant client is developing HELLP syndrome. During labor, which order should the nurse question?
Prepare for epidural anesthesia.
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
at 28 weeks' gestation and again within 72 hours after birth Explanation: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.
A pregnant client is hospitalized because of preeclampsia. Magnesium sulfate is ordered to prevent eclampsia. When preparing to administer the magnesium sulfate, the nurse would ensure that which medication would be readily available?
calcium gluconate Explanation: When administering magnesium sulfate, the nurse would make sure that calcium gluconate is readily available should the client develop signs and symptoms of magnesium toxicity. Hydralazine, labetalol, and nifedipine are other drugs that may be used to control hypertension instead of magnesium sulfate.
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?
Assess the client's vital signs.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?
Palpate the fundus and check fetal heart rate.
A pregnant client with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful?
The client delivers a full-term fetus at 39 weeks' gestation. Explanation: Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation. Spontaneous rupture of the membranes could indicate that the procedure was not successful. Vaginal bleeding could indicate another health problem or that the procedure was not successful. This procedure does not impact the client's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.
A nurse is monitoring the serum drug level of a pregnant client with preeclampsia who is receiving a continuous infusion of magnesium sulfate. For which level would the nurse continue the infusion?
6.8 mg/100ml Explanation: Therapeutic serum blood levels for magnesium sulfate should be maintained at 5-8 mg/100 ml. If blood serum levels rise above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?
deep tendons reflexes 2+ Explanation: With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.
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 client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy?
Abdominal ultrasound Explanation: An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.
A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?
Chromosomal defects in the fetus Explanation: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
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 nurse is conducting a presentation for a group of pregnant women about conditions that can occur during pregnancy and that place the woman at high-risk. When discussing blood incompatibilities, which measure would the nurse explain as most effective in preventing isoimmunization during pregnancy?
Rho(D) immune globulin administration to Rh-negative women Explanation: Rh incompatibility can be prevented with the use of Rho(D) immune globulin. Hemolysis associated with ABO incompatibility is limited to mothers with type O blood and their fetuses with type A or B blood. Amniocentesis would be appropriate for treatment of polyhydramnios, not isoimmunization. Cerclage is a treatment for cervical insufficiency.
A pregnant client at 32 weeks' gestation is treated with magnesium sulfate for seizure management. The nurse assesses which of the following for evidence of magnesium toxicity?
absence of knee jerk response Explanation: Magnesium sulfate toxicity is characterized by an absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, not frequency of micturition, is seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat seizures associated with hypertension and proteinuria in pregnancy, and therefore decreases the blood pressure. It does not cause an increase in blood pressure. There is respiratory depression, and not an increased rate of respiration, with magnesium sulfate toxicity.
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?
elevated liver enzymes
A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The client states, "It started all of a sudden and now it seems to have stopped." Placenta previa is suspected. Which action should the nurse implement immediately for this client?
Determine fetal heart sounds using an external monitor. Explanation: For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal monitoring is contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both the pregnant client and fetus. The decision to birth the fetus depends on the point at which a diagnosis of placenta previa is made and the age of the gestation. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the fetal heart rate to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, pregnant client vital signs are good, and the fetus is not yet 36 weeks of age, a client is usually managed by expectant watching.
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?
assessing fetal heart tones by use of an external monitor Explanation: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.
A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation Recent onset of bright red vaginal bleeding, more than with previous episode No uterine contractions at present Fetal heart rate within normal range Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect?
placenta previa Explanation: The assessment findings suggest placenta previa, a bleeding condition that occurs during the last two trimesters of pregnancy. It is characterized by slight, bright red vaginal bleeding that initially stops spontaneously and then recurs later in amounts greater than the initial episode; absence of pain/contractions; soft, relaxed uterine tone; and a fetal heart rate within normal parameters. Placental abruption (abruptio placentae) is characterized by a sudden onset with concealed or visible dark vaginal bleeding, uterine tenderness and pain, a firm or rigid uterus, and fetal distress. The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. If ectopic rupture or hemorrhage occurs before treatment begins, symptoms may worsen and include: severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity feelings of faintness referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation hypotension marked abdominal tenderness with distention hypovolemic shock Polyhydramnios is initially suspected when uterine enlargement, maternal abdominal girth, and fundal height are larger than expected for the fetus's gestational age. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Shortness of breath and uterine contractions from overstretching may occur. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present.