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The nurse is identifying nursing diagnoses for a patient with gestational hypertension. Which diagnosis would be the most appropriate for this patient?
Ineffective tissue perfusion related to vasoconstriction of blood vessels Explanation: In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.
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 Explanation: The client with a multifetal pregnancy must be made aware of the risks posed by preterm labor. There is no corresponding increase in the risk for hypertension or blood incompatabilities. Parenting skills are secondary to physiologic needs at this point.
The nurse is monitoring a pregnant patient who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do?
Stop the current infusion. Explanation: When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time and provide the patient with more magnesium sulfate. The infusion rate should not be increased because this could lead to cardiac dysrhythmias and respiratory depression.
A pregnant client has an Rh-negative blood type. Following the birth of the client's infant, the nurse administers her Rho(D) immune globulin. The purpose of this is to:
prevent maternal D antibody formation. Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies.
A pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient?
ssess fetal heart sounds with an external monitor. Explanation: For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine contractions are 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 mother and child. To ensure an adequate blood supply to the patient and fetus, the patient should be placed immediately on bed rest in a side-lying position.
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?
fetal distress related to hypoxia Explanation: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.
A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?
"Come to the health facility with any vaginal material passed." Explanation: This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so it can be assessed for this.
The nurse is is giving discharge instructions to a client who experienced a complete spontaneous abortion. Which question should the nurse prioritize at this time?
"Do you have someone to talk to, or may I give you the names and numbers for some possible grief counselors?" Explanation: When a woman has a spontaneous abortion, or miscarriage, one important consideration is the emotional needs of the woman once she is home. She may not want to talk about the loss for a period of time, but the nurse needs to determine her support system for the future. Asking the woman if she is "going to try again" is an inappropriate question for the nurse to ask and diminishes the experience of having a spontaneous abortion. It would be inappropriate to point out the woman is not the only one to have this experience or to offer ways to prevent it from happening in the future. The woman needs to deal with this situation first before moving on to a possible "next" time.
A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse?
"I can understand your need to find an answer to what caused this. Let's talk about this further." Explanation: Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
A client is 11 weeks pregnant after many years trying to conceive. After arriving home from a normal prenatal visit, she experiences mild cramping and has a gush of bright red vaginal bleeding. She calls the nurse and reports having soaked a pad with fresh blood in fewer than 30 minutes. The uterine cramping is worsening. What is the most appropriate response from the nurse?
"You need to seek immediate attention from the primary care provider." Explanation: Pregnancy loss during the early weeks of pregnancy may seem like a heavy menstrual period. A primary care provider should assess blood loss of this amount with or without uterine cramping as soon as possible.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?
Ectopic pregnancy Explanation: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.
A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which measure will be important for the nurse to include in the care plan?
Institute and maintain seizure precautions. Explanation: The woman with severe preeclampsia should be maintained on complete bed rest in a dark and quiet room to avoid stimulation. The client is at risk for seizures; therefore, institution and maintenance of seizure precautions should be in place.
A patient recovering from an uneventful vaginal delivery is prescribed Rho(D) immune globulin (RhIG). What should the nurse explain to the patient regarding the purpose of this medication?
It prevents maternal D antibody formation. Explanation: Rho(D) immune globulin (RhIG) is given to Rh-negative pregnant patients to prevent the formation of maternal antibodies to the Rh-positive blood type of the developing fetus. This medication does not prevent fetal Rh blood formation, stimulate maternal immune antigens, or promote maternal antibody formation.
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?
Monitor the client's vital signs and bleeding. Explanation: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending abortion. Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.
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. Explanation: The classic signs of abruptio placentae are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
A pregnant patient 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 patient's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.
A woman with a recent incomplete abortion is to receive therapeutic misoprostol. The nurse understands that the rationale for administering this drug is to:
ensure passage of all the products of conception. Explanation: Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an incomplete abortion to ensure passage of all the products of conception. Rh (D) immunoglobulin is used to suppress the immune response and prevent isoimmunization.
After an examination, a client has been determined to have an unruptured ectopic pregnancy. Which medication would the nurse anticipate being prescribed?
methotrexate Explanation: Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
A 28-year-old primigravida client with type 2 diabetes mellitus comes to the health care clinic for a routine first trimester visit reporting frequent episodes of fasting blood glucose levels being lower than normal, but glucose levels after meals being higher than normal. What should the nurse point out that these episodes are most likely related to?
normal response to the pregnancy Explanation: This is a normal response to the pregnancy. During pregnancy, tissues become resistant to insulin to provide sufficient levels of glucose for the growing fetus. This can result in three normally occurring responses: blood glucose levels are lower than normal when fasting; blood glucose levels are higher than normal after meals; and insulin levels are increased after meals. The various hormones will prevent the mother from using most of the insulin produced to allow the extra glucose to get to the growing fetus.
A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?
pregnancy loss Explanation: The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for pregnancy loss. Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.