Maternity Chapter 10: Complications of Pregnancy
Which maternal condition always necessitates birth by cesarean section? a. Partial abruptio placentae b. Total placenta previa c. Ectopic pregnancy d. Eclampsia
ANS: B
Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome? a. Abdominal palpation b. Venous sample of blood c. Checking deep tendon reflexes d. Auscultation of the heart and lungs
ANS: A
Which is the only known cure for preeclampsia? a. Magnesium sulfate b. Delivery of the fetus c. Antihypertensive medications d. Administration of aspirin (ASA) every day of the pregnancy
ANS: B
What should the nurse recognize as evidence that the client is recovering from preeclampsia? a. 1+ protein in urine b. 2+ pitting edema in lower extremities c. Urine output >100 mL/hr d. Deep tendon reflexes +2
ANS: C
Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication? a. Drowsiness b. Urinary output of 20 mL/hr c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/min
ANS: C
Which finding in the assessment of a client following an abruption placenta could indicate a major complication? a. Urine output of 30 mL in 1 hour b. Blood pressure of 110/60 mm Hg c. Bleeding at IV insertion site d. Respiratory rate of 16 breaths/min
ANS: C
A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion.
ANS: D
Which finding in the exam of a client with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion? a. Presence of backache b. Rise in hCG level c. Clear fluid from vagina d. Pelvic pressure
ANS: C
What is the value of the main line fluid rate for your client, whose total fluid intake is ordered at 150 mL/hr and who is also being given magnesium sulfate at 1 g/hr (1 g = 25 mL/hr) IV piggyback and pitocin at 15 mU/min (l mU/min = 1 mL/hr) IV piggyback.
ANS: 110 The rate of infusion of magnesium sulfate (25 mL/hr) and pitocin (15 mL/hr) equals 40 mL/hr. Subtracting the 40 mL from the total ordered of 150 mL leaves 110 mL of main line fluid to be infused per hour.
Rank the following interventions in the correct sequence for the client diagnosed with gestational trophoblastic disease: a. IV oxytocin b. Vacuum aspiration and curettage c. Evaluation of hCG level every week d. Lab studies for type, crossmatch, and coagulation
ANS: D, B, A, C Diagnostic studies to determine client status are completed first, followed by evacuation of the uterus by vacuum aspiration and curettage. Once the uterus is empty, IV oxytocin is given to contract the uterus and control bleeding. Evaluation of hCG levels will be done weekly until no longer detected.
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following? a. Hemorrhage is the major concern. b. She will be unable to conceive in the future. c. Bed rest and analgesics are the recommended treatment. d. A D&C will be performed to remove the products of conception.
ANS: A
A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days' duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder. The client's last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect? a. Ectopic pregnancy b. Appendicitis c. Food poisoning d. Gastroenteritis
ANS: A
A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome? a. Platelet count of 50,000/L b. Liver enzyme levels within normal range c. Negative for edema d. No evidence of nausea or vomiting
ANS: A
A laboratory finding indicative of DIC is: a. decreased fibrinogen. b. increased platelets. c. increased hematocrit. d. decreased thromboplastin time.
ANS: A
A patient reports to the emergency room nurse that she is 10 weeks pregnant, with unilateral pelvic pain, shoulder pain, and faintness. Her color is pale, she is diaphoretic, and her heart rate is 140 bpm. What is the nurse's priority action? a. Initiate an ordered IV of lactated Ringer's at 200 mL/hr. b. Take the patient for her ordered pelvic ultrasound. c. Ask the patient if she has had any recent vaginal bleeding. d. Ask the patient if she has ever been told she has had salpingitis.
ANS: A
As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that: a. immediate birth is required. b. the client should be transferred to the critical care unit for closer observation. c. RhoGAM should be administered. d. a tetanus shot should be administered.
ANS: A
Spontaneous termination of a pregnancy is considered to be an abortion if: a. the pregnancy is less than 20 weeks. b. the fetus weighs less than 1000 g. c. the products of conception are passed intact. d. there is no evidence of intrauterine infection.
ANS: A
The clinic nurse is reviewing home care dietary instructions for the patient diagnosed with mild preeclampsia at 34 weeks' gestation. The nurse determines that the client requires additional information when she makes which statement? a. "I will limit my salt intake to 2 grams per day." b. "I will drink no less than 2500 mL of fluid per day." c. "I will make sure I eat 4 sources of protein per day." d. "My overall intake of calories per day should be around 2500."
ANS: A
The emergency room charge nurse calls the labor and birth charge nurse and reports the ambulance is en route with a seizing pregnant patient at 36 weeks' gestation. What medication will the charge nurse most likely direct the staff nurse to prepare to administer immediately on the patient's arrival to the labor and birth unit? a. Magnesium sulfate (magnesium) b. Hydralazine (Apresoline) c. Carbamazepine (Tegretol) d. Terbutaline (Brethine)
ANS: A
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding? a. Treated 1 year ago for pelvic inflammatory disease (PID) b. Oral contraception for last 3 years c. Urinary frequency for 1 week d. Irregular cycles for 1 year prior to conception
ANS: A
Which finding should be the nurse's priority in a client suspected as having gestational trophoblastic disease? a. Uterine contractions b. Nausea and vomiting c. Blood pressure of 130/80 mm Hg d. Increase discharge of vaginal mucus
ANS: A
Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa? a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding or leakage of amniotic fluid d. Determining frequency, duration, and intensity of contractions
ANS: A
The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms? (Select all that apply.) a. Pelvic pain b. Missed period c. Abdominal pain d. Unanticipated heavy bleeding e. Vaginal spotting or light bleeding
ANS: A, B, C, E A missed period or spotting can easily be mistaken by the client as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about 50% of women, shoulder and neck pain occurs because of irritation of the diaphragm from the hemorrhage.
The physician suspects that the client may have gestational trophoblastic disease. Which clinical manifestations support this diagnosis? (Select all that apply.) a. Increased levels of beta-hCG in the serum b. Fundal height correlating with reported gestational age c. Vaginal bleeding d. Vomiting e. Maternal hypotension
ANS: A, C, D In gestational trophoblastic disease (molar pregnancy), the following clinical manifestations would appear: increased serum beta-hCG levels, increased size of the uterus related to gestational age, nausea and vomiting, and evidence of vaginal bleeding. Development of preeclampsia earlier in the pregnancy would be noted, resulting in hypertension, not hypotension.
A client who was pregnant had a spontaneous abortion at approximately 4 weeks' gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of "crampy" abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100 F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis? a. Ectopic pregnancy b. Uterine infection c. Gestational trophoblastic disease d. Endometriosis
ANS: B
A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted? a. Obtain the patient's weight. b. Take the patient's vital signs. c. Start an IV with lactated Ringer's at 75 mL/hr. d. Ask support persons to leave the birthing room.
ANS: B
A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL. What is the nurse's priority action? a. Stop the infusion of magnesium. b. Assess the patient's respiratory rate. c. Assess the patient's deep tendon reflexes. d. Notify the health care provider of the magnesium level.
ANS: B
An abortion when the fetus dies but is retained in the uterus is called: a. inevitable. b. missed. c. incomplete. d. threatened.
ANS: B
The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to: a. monitor uterine contractions. b. assess fetal heart rate and maternal vital signs. c. place clean disposable pads to collect any drainage. d. perform a venipuncture for hemoglobin and hematocrit levels.
ANS: B
Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae? a. Saturated perineal pad in 1 hour b. Pain level 0 on a scale of 0 to 10 c. Cervical dilation at 2 cm d. Fetal heart rate at 160 bpm
ANS: B
Which assessment finding indicates an adverse response to magnesium sulfate? a. Urine output of 30 mL/hr b. Respiratory rate of 11 breaths/min c. Hypoactive patellar reflex d. Blood pressure reading of 110/80 mm Hg
ANS: B
Which assessment finding suggests that your laboring client's blood magnesium level is too high? a. Hyperactive reflexes b. Absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr
ANS: B
Which data found on a client's health history would place her at risk for an ectopic pregnancy? a. Ovarian cyst 2 years ago b. Recurrent pelvic infections c. Use of oral contraceptives for 5 years d. Heavy menstrual flow of 4 days' duration
ANS: B
Which explanation of a marginal placenta previa would the nurse provide to her client? a. The placenta is in the lower uterus, completely covering the internal cervical os. b. The placenta is in the lower uterus, more than 3 cm from the internal cervical os. c. The placenta is in the lower uterus, less than 3 cm from the internal cervical os. d. The placenta is in the lower uterus, at the edge and partially covering the cervical os.
ANS: B
Which finding could cause the nurse to suspect gestational trophoblastic disease in a client at 8 weeks' gestation? a. Blood pressure of 128/70 mm Hg b. Fundal height of 12 cm c. Nausea and vomiting d. Weight gain of 3 pounds
ANS: B
Which information should the labor nurse recognize as being pertinent to a possible diagnosis of abruptio placentae? a. Low back pain b. Firm, tender uterus c. Regular uterine contractions d. Scant vaginal mucus drainage
ANS: B
Which intervention would be the most effective if your client who is on magnesium sulfate has a respiratory rate of 10 breaths/min? a. Give oxygen by mask at 8-10 L/min. b. Administer calcium gluconate via IV pyelogram (IVP). c. Arouse client with tactile stimulation. d. Continually assess pulse oximeter levels.
ANS: B
Which orders should the nurse expect for a client admitted with a threatened abortion? a. NPO b. Pad count c. Ritodrine IV d. Meperidine (Demerol), 50 mg now
ANS: B
Which would indicate concealed hemorrhage in abruptio placentae? a. Bradycardia b. Hard boardlike abdomen c. Decrease in fundal height d. Decrease in abdominal pain
ANS: B
A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to: a. advise her to cut down on fast foods that are high in fat. b. caution her to avoid salty foods and to return in 2 weeks. c. assess weight gain, location of edema, and urine for protein. d. recommend she stay home from school for a few days to reduce stress.
ANS: C
A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic. c. anticonvulsant. d. antihypertensive.
ANS: C
A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? a. +1 b. +2 c. +3 d. +4
ANS: C
A patient presents to labor and birth with complaints of persistent acute back pain at 36 weeks' gestation. The nursing assessment reveals a taught abdomen, fundal height at 40 cm, and late decelerations, with an FHR range of 124 to 128 bpm. The nurse will implement the protocol for which obstetric condition? a. Placenta previa b. Hypovolemic shock c. Abruptio placentae or abruption d. DIC
ANS: C
Fraternal twins are delivered by your Rh-negative client. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the: a. direct Coombs test of twin A. b. direct Coombs test of twin B. c. indirect Coombs test of the mother. d. transcutaneous bilirubin level for both twins.
ANS: C
The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia? a. Edema b. Proteinuria c. Glucosuria d. Hypertension
ANS: C
The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa? a. Female fetus, Mexican-American, primigravida b. Male fetus, Asian-American, previous preterm birth c. Male fetus, African-American, previous cesarean section d. Female fetus, European-American, previous spontaneous abortion
ANS: C
The most appropriate nursing action for the client complaining of continuous headache 24 hours postpartum after a normal vaginal birth is to: a. encourage bed rest. b. administer analgesic. c. assess blood pressure. d. assess for pitting edema.
ANS: C
The primary symptom present in abruptio placentae that distinguishes it from placenta previa is: a. vaginal bleeding. b. rupture of membranes. c. presence of abdominal pain. d. changes in maternal vital signs.
ANS: C
What is the priority nursing intervention for the client who has had an incomplete abortion? a. Methylergonovine (Methergine), 0.2 mg IM b. Preoperative teaching for surgery c. Insertion of IV line for fluid replacement d. Positioning of client in left side-lying position
ANS: C
Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? a. Blood pressure of 120/80 mm Hg b. Complaint of frequent mild nausea c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day weeks ago
ANS: C
You are taking care of a client who had a therapeutic abortion following an episode of vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks postprocedure as a follow-up to medical care. Which result indicates that additional intervention is needed? a. Hemoglobin, 13.2 mg/dL b. White blood cell count, 10,000 mm3 c. Beta-hCG detected in serum d. Fasting blood glucose level, 80 mg/dL
ANS: C
Which assessment finding indicates the development of preeclampsia in the antepartum client? a. Slight edema of feet and ankles. b. Increased urine output c. Blood pressure of 128/80 mm Hg d. Weight gain of 3 pounds in 1 week
ANS: D
Which assessment finding on the fetal monitor strip supports a diagnosis of abruptio placentae? a. FHR of 150 bpm b. Moderate variability of FHR c. Contractions every 3 minutes d. Uterine resting tone of 30 mm Hg
ANS: D Abruptio placentae results in uterine irritability and a high resting uterine tone. A normal resting tone is from 5 to 15 mm Hg; FHR of 150 bpm, moderate variability of FHR, and contractions every 3 minutes are normal labor findings.
The nurse is providing care to a laboring woman who is Rh-negative. The patient has a standing prescription to receive RhoGAM, if indicated. When will the nurse plan on administering the RhoGAM, if indicated? a. Approximately 2 hours prior to birth b. At the birth of the placenta c. One hour after the birth of the infant d. Between 48 and 72 hours after birth of the infant
ANS: D If the mother is Rh-negative, umbilical cord blood is taken at birth to determine blood type, Rh factor, and antibody titer (direct Coombs test) of the newborn. Rh-negative unsensitized mothers who give birth to Rh-positive infants are given an intramuscular injection of Rho(D) immune globulin (RhoGAM) within 72 hours after birth. If RhoGAM is given to the mother in the first 72 hours after the birth of an Rh-positive infant, Rh antigens present in her blood are destroyed before she forms antibodies to the Rh factor. If the infant is Rh-negative, Rh antibodies are not formed and RhoGAM is not necessary. Patients of the Jehovah's Witness faith decline blood-based products, and RhoGAM is derived from blood. It is the responsibility of the nurse to make sure that patients of this faith understand the characteristics of RhoGAM and are fully informed of the consequences of declining the administration of RhoGAM.
For the client who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to: a. 6:30 AM on January 13. b. 6:30 PM on January 13. c. 6:30 PM on January 14. d. 6:30 AM on January 15.
ANS: A Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant. 6:30 PM on January 13, 6:30 PM on January 14, and 6:30 AM on January 15 do not fall within the established time frame.
In addition to obtaining vital signs and FHT, what is a priority for the client with placenta previa? a. Determining cervical dilation b. Monitoring uterine contractions c. Estimating blood loss d. Starting a Pitocin drip
ANS: C
Which interventions may be indicated for the clinical management of hyperemesis gravidarum (HEG)? (Select all that apply.) a. Pyridoxine b. Total parenteral nutrition (TPN) for severe cases c. Promethazine (Phenergan) d. Levaquin (Levofloxacin) e. Omeprazole (Prilosec) f. Diphenhydramine (Benadryl)
ANS: A, B, C, E, F Pyridoxine (vitamin B6) may be indicated for the treatment of HEG. TPN is indicated for severe conditions. Phenergan, an antiemetic, and Prilosec, a gastric acid inhibitor, are also used for treatment of this condition. Benadryl is also used for treatment. An antibiotic such as Levaquin is not indicated for the treatment of this disease.
47. Which of these interventions should the nurse recognize as the priority for the client diagnosed with an intact tubal pregnancy? a. Assessment of pain level b. Administration of methotrexate c. Administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan
ANS: B
A client is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. Which potential problem should be investigated? a. Placenta previa b. Hydatidiform mole c. Abruptio placentae d. Disseminated intravascular coagulation (DIC)
ANS: B
A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? a. Increase the client's IV fluids. b. Administer calcium gluconate. c. Vigorously stimulate the client. d. Instruct the client to take deep breaths.
ANS: B
Rh incompatibility can occur if the client is Rh-negative and the: a. fetus is Rh-negative. b. fetus is Rh-positive. c. father is Rh-positive. d. father and fetus are both Rh-negative.
ANS: B ]
The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.) a. Cool, clammy skin b. Altered sensorium c. Pulse oximeter reading of 95% d. Respiratory rate of less than 12 breaths/min e. Absence of deep tendon reflexes
ANS: B, D, E Signs of magnesium toxicity include the following: • Respiratory rate of less than 12 breaths/min (hospitals may specify a rate < 14 breaths/min) • Maternal pulse oximeter reading lower than 95% • Absence of deep tendon reflexes • Sweating, flushing • Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented) • Hypotension • Serum magnesium value above the therapeutic range of 4 to 8 mg/dL Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity.
A preeclamptic patient is receiving an IV infusion of magnesium sulfate. On assessment, the nurse notes that the patient's urinary output has been 20 mL/hr for the past 2 hours and her deep tendon reflexes are absent. The health care provider prescribes calcium gluconate, 1 g of a 10% solution. The standard rate of infusion is 1 mL/min. How many minutes will it take for the nurse to administer the prescribed calcium? a. 1 b. 5 c. 10 d. 15
ANS: C A 10% solution contains 10 g in 100 mL. X minutes = 1 minute/ 1 mL x 100 mL/ 10 g x 1 g = 10 minutes
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL. a. 1800 b. 450 c. 900 d. 90
ANS: C One g equals 1 mL of blood.
A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring? a. Placental previa b. Active labor has started c. Placental abruption d. Hidden placental abruption
ANS: D
A client with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting? a. Pregnancy-induced hypertension (PIH) b. Gestational hypertension c. Preeclampsia superimposed on chronic hypertension d. Undiagnosed chronic hypertension
ANS: D
A placenta previa when the placental edge just reaches the internal os is called: a. total. b. partial. c. low-lying. d. marginal.
ANS: D
A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following? a. She should be isolated from her family. b. This condition is caused by psychogenic factors. c. The treatment is similar to that for morning sickness. d. She should be assessed for signs of dehydration and starvation.
ANS: D
In which situation would a dilation and curettage (D&C) be indicated? a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks
ANS: D
The nurse is providing care to a patient who just learned her baby has died in utero at 26 weeks' gestation. What is the nurse's next action? a. Contact the patient's clergy member. b. Enroll the patient in a grief and loss class. c. Determine if the patient is a victim of violence. d. Ask the patient when she last felt the baby move.
ANS: D
