OB Exam 2: Chapter 15
The nurse is supervising care in the emergency department. Which situation requires immediate intervention? 1. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20. 2. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports the presence of fetal movement. 3. Spotting of pinkish brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour. 4. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer solution running at 125 mL/hour.
Answer: 1 Explanation: 1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the client has an IV started, this client is the least stable, and therefore the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual fetal movements reduces this client's risk of needing immediate intervention. 3. Bleeding in the first trimester can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume.
The community nurse is caring for a client at 32 weeks' gestation diagnosed with preeclampsia. Which statement indicates that additional information is needed about the health problem? 1. "My urine may become darker and smaller in amount each day." 2. "Lying on my left side as much as possible is good for the baby." 3. "I should call the doctor if I develop a headache or blurred vision." 4. "Pain in the top of my abdomen is a sign my condition is worsening."
Answer: 1 Explanation: 1. Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. Oliguria should be reported to the healthcare provider. 2. Left lateral position maximizes uterine and renal blood flow and therefore is the optimal position for a client with preeclampsia. 3. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the healthcare provider. 4. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the healthcare provider.
The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask? 1. "Do you have a safe place where you can go?" 2. "What did you do to make your spouse so angry?" 3. "How many times has this happened in the past?" 4. "Will you be pressing charges against your spouse?"
Answer: 1 Explanation: 1. This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus. 2. This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused client. 3. Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority. 4. Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance.
A pregnant client diagnosed with Chlamydia trachomatis infection is refusing treatment. What effects on the fetus should the nurse explain might occur if treatment is waived? Select all that apply. 1. Fetal death 2. Premature labor 3. Newborn conjunctivitis 4. Chlamydial pneumonia 5. Ophthalmia neonatorum
Answer: 1, 2, 3, 4 Explanation: 1. Fetal death is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 2. Premature labor is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 3. An infant of a woman with untreated chlamydial infection may develop newborn conjunctivitis. 4. An infant of a woman with untreated chlamydial infection may develop chlamydial pneumonia. 5. Ophthalmia neonatorum is associated with gonorrhea.
A client is suspected of having a hydatidiform mole. What should the nurse expect to assess in this client? Select all that apply. 1. Elevated blood pressure 2. Absence of fetal heart tones 3. Frequent urination and thirst 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height
Answer: 1, 2, 4, 5 Explanation: 1. Manifestations of preeclampsia are associated with a hydatidiform mole, which would include an elevated blood pressure. 2. Fetal heart sounds are absent with a hydatidiform mole because a fetus is not developing in the uterus. 3. Frequent urination and thirst are not manifestations of hydatidiform mole. 4. Dark brown vaginal discharge, similar to prune juice, occurs because of liquefaction of the uterine clot. 5. Uterine enlargement greater than expected for gestational age is a classic sign of a complete mole, which is present in about half of cases. Enlargement is due to the proliferating trophoblastic tissue and to a large amount of clotted blood.
A pregnant client is in a motor vehicle crash and needs surgery to repair a fractured lower leg. What special precautions will this client need during and after the surgery? Select all that apply. 1. Prepare for intubation. 2. Insert a nasogastric tube. 3. Maintain on strict bed rest. 4. Insert an indwelling urinary catheter. 5. Apply sequential compression devices (SCDs).
Answer: 1, 2, 4, 5 Explanation: 1. Pregnancy causes increased secretions of the respiratory tract and engorgement of the nasal mucous membrane, often making breathing through the nose difficult. Consequently, pregnant women often need an endotracheal tube to maintain an airway during surgery. 2. The decreased intestinal motility and delayed gastric emptying that occur in pregnancy increase the risk of vomiting when anesthetics are given and during the postoperative period. A nasogastric tube may be recommended before major surgery. 3. Exercises in bed should be encouraged along with early ambulation after surgery. 4. An indwelling urinary catheter prevents bladder distention, decreases risk of injury to the bladder, and permits monitoring of output. 5. SCDs during and after surgery help prevent venous stasis and the development of thrombophlebitis.
Which situation in the high-risk antepartal unit requires immediate intervention? 1. Fetal monitoring is being performed on a client in her third trimester who is scheduled for a cholecystectomy tomorrow. 2. A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position. 3. Oxygen is being administered at 2 L via nasal cannula to a client in her third trimester who underwent a urolithotomy today. 4. The client in her third trimester who returned from bowel resection surgery has a nasogastric tube attached to intermittent suction.
Answer: 2 Explanation: 1. Fetal monitoring prior to, during, and after surgery on pregnant clients is important to assess the fetal condition. 2. A client undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed under the right hip. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic. 3. Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation. 4. Due to the decreased peristalsis of pregnancy, pregnant clients who undergo abdominal surgery are at risk for vomiting. A nasogastric tube is placed to prevent vomiting
The nurse is preparing teaching on maternal-fetal ABO incompatibility for antepartum clients. Which statement should the nurse include in the teaching information? 1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. 3. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal red blood cells (RBCs). 4. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.
Answer: 2 Explanation: 1. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 3. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal red blood cells (RBCs). 4. Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type
A newly admitted client at 32 weeks' gestation is experiencing a sudden onset of intense nausea and a frontal headache for the past 2 days. The client's initial blood pressure is 158/98, and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing? 1. Ordering a low-protein diet for the client 2. Conducting a urine dipstick test to assess for proteinuria 3. Placing a wedge under the client's left hip so that she is in a right lateral tilt position 4. Administering diuretics and facilitating a dietary regimen of strict sodium restriction
Answer: 2 Explanation: 1. This client's signs and symptoms are consistent with preeclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/day) to replace protein lost in the urine. 2. This client's signs and symptoms are consistent with preeclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria. 3. This client's signs and symptoms are consistent with preeclampsia. Appropriate interventions include instituting bed rest with the client positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion. 4. This client's signs and symptoms are consistent with preeclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating preeclampsia.
) A pregnant woman is being excavated from the back seat of a motor vehicle after a crash. In which order should this victim receive emergency care? 1. Apply oxygen. 2. Establish an airway. 3. Monitor fetal activity. 4. Position on the left side. 5. Administer intravenous fluids.
Answer: 2, 1, 5, 4, 3 Explanation: 1. Applying oxygen occurs after an airway is established. 2. The first action is to establish an airway. 3. Monitoring fetal activity occurs after the victim is stabilized. 4. Positioning on the left side helps prevent hypotension. 5. Intravenous fluids are provided to prevent shock and maintain circulation.
The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse? 1. Administer rubella vaccine. 2. Ask if she is breast- or bottlefeeding. 3. Determine if RhoGAM has been given. 4. Discuss the discharge education with the client.
Answer: 3 Explanation: 1. The client is rubella immune and does not need the rubella vaccine. 2. This is important but is not the top priority. 3. The client is A-negative and the newborn B-positive. The client needs RhoGAM prior to discharge. Without RhoGAM, the client will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy. 4. Discharge education is always important, but in this case it is not the most important action
Which maternal-child client should the nurse see first? 1. Blood type B, Rh-positive 2. Blood type O, Rh-negative 3. Direct Coombs test positive 4. Indirect Coombs test negative
Answer: 3 Explanation: 1. This client's blood type creates no problems. 2. This client is Rh-negative, but there is no indication that the alloimmunization has occurred. 3. A direct Coombs test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia. 4. An indirect Coombs test looks for Rh antibodies in the maternal serum; a negative result indicates the client has not been alloimmunized.
A pregnant client at 14 weeks' gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Encourage clear liquids orally. 3. Give 1 L of lactated Ringer solution IV. 4. Administer 30 mL Maalox (magnesium hydroxide) orally.
Answer: 3 Explanation: 1. Weighing the client provides information on weight gain or loss, but it is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids. 2. The client needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. 3. The vital signs indicate hypovolemia. Giving this client a liter of lactated Ringer solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. 4. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids.
A client who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing? 1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM). 2. Obtain an antibody screen (indirect Coombs test) to determine whether the client has developed isoimmunity. 3 Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia. 4. Notify the primary care provider and document the potential need for treatment of fetal hemolytic anemia in the baby after delivery.
Answer: 3 Explanation: 1. RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood. 2. An antibody screen (indirect Coombs test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen. 3. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert healthcare providers to the need for carefully assessing the newborn for the development of hyperbilirubinemia. 4. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia.
The nurse instructs a client on the importance of reducing exposure to infections while pregnant. Which client statement indicates that teaching has been effective? 1. "My genital herpes infection will have no effect on my baby." 2. "Because I have toxoplasmosis, my baby might be born with an abnormally long body." 3. "The rubella infection I experienced in my second trimester may lead me to become deaf." 4. "My baby may develop a serious blood infection because I have group B strep in my vagina."
Answer: 4 Explanation: 1. Primary herpes simplex infection poses the greatest risk to both the mother and her infant. Primary infection has been associated with spontaneous abortion, low birth weight, and preterm birth. Transmission to the fetus almost always occurs after the membranes rupture and the virus ascends or during birth through an infected birth canal. 2. Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis. 3. Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella. 4. Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor.
A postpartum client with blood type A, Rh-negative delivered a newborn with blood type AB, Rh-positive. Which statement indicates that teaching about this blood type inconsistency has been effective? 1. "Because my baby is Rh-positive, I do not need RhoGAM." 2. "Before my next pregnancy, I will need to have a RhoGAM shot." 3. "If my baby had the same blood type I do, it might cause complications." 4. "I need to get RhoGAM so I do not have problems with my next pregnancy."
Answer: 4 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization. 2. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM). The injection must be given within 72 hours after delivery to prevent alloimmunization. 3. It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. 4. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy.
A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client's condition is getting worse? 1. Reflexes 2+ 2. Platelet count 150,000 3. Blood pressure 158/104 4. Urinary output 20 mL/hour
Answer: 4 Explanation: 1. The reflexes are normal at 2+. 2. The platelet count is normal, though it is at the lower end. 3. The blood pressure has not had a significant rise. 4. The decrease in urine output is an indication of decrease in glomerular filtration, which indicates a loss of renal perfusion. The assessment finding most abnormal and life threatening is the urine output change.
The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Clear fluid is leaking from the vagina." 3. "Client is positioned in a left lateral tilt." 4. "Entrance wound present below the umbilicus."
Answer: 4 Explanation: 1. These are normal vital signs, indicating a hemodynamically stable client. 2. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time. 3. Positioning the client in a lateral tilt position prevents vena cava syndrome. 4. Penetrating abdominal trauma has a 59% to 80% fetal injury rate. This fetus is at great risk for injury.
A 28-year-old woman at 16 weeks' gestation being screened for ABO incompatibility learns that her blood contains anti-A antibodies. What should the nurse explain about this finding? 1. "You may have contracted anti-A antibodies as a result of a viral infection." 2. "It's most likely that you contracted anti-A antibodies through sexual activity." 3. "Anti-A antibodies are inherited; usually, they are genetically passed down from father to daughter." 4. "Anti-A antibodies occur naturally, as a result of exposure to foods and different infections."
Answer: 4 Explanation: 1. Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens through infection by gram-negative bacteria and not viruses. 2. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not contracted through sexual activity. 3. Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not inherited. 4. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria.
