OB/Peds Ch. 21 Sudden Pregnancy Complication
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?
elevated liver enzymes Explanation: HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia is not a part of this syndrome. HELLP may increase the woman's risk for DIC but it is not an assessment finding.
A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?
"Purse-string sutures are placed in the cervix to prevent it from dilating." Explanation: The cerclage, or purse string suture is inserted into the cervix to prevent preterm cervical dilatation and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.
What is the drug methylergonovine maleate used for?
Uterine contraction Explanation: Methylergonovine maleate or carboprost tromethamine are other medications that may be ordered to stimulate the uterine muscle to contract.
A pregnant client is admitted to a health care unit with disseminated intravascular coagulation (DIC). Which prescription is the nurse most likely to receive regarding the therapy for such a client?
Administer cryoprecipitate and platelets. Explanation: In a pregnant client with DIC, the nurse may be told to administer cryoprecipitate and platelets. Whole blood does not contain clotting factors. Therefore, a ratio of 4 units of blood to 1 unit of fresh frozen plasma, and not 1 unit of blood to 4 units of frozen plasma, should be considered. The nurse should aim at maintaining the client's hematocrit above 30% and not just 20%. The nurse should expect one unit of blood to increase the hematocrit by 1.5 g/dl (15 g/L) not 3g/dl (30 g/L).
A woman at 10 weeks gestation comes to the clinic for an evaluation. Which assessment finding should the nurse prioritize?
fundal height measurement of 18 cm Explanation: A fundal height of 18 cm is larger than expected and should be further investigated for gestational trophoblastic disease (hydatidiform mole). One of the presenting signs is the uterus being larger than expected for date. Mild nausea would be a normal finding at 10 weeks' gestation. Blood pressure of 120/84 would not be associated with hydatidiform mole and depending on the woman's baseline blood pressure may be within acceptable parameters for her. Bright red spotting might suggest a spontaneous abortion.
A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?
Confine the client to bed rest in a darkened room. Explanation: With severe preeclampsia, 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 client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?
Prevent maternal seizures Explanation: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as its primary goal as decrease in blood pressure, decrease in protein in the urine, or the reversal of edema.
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?
Reflexes Explanation: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.
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.
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 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response?
"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." Explanation: Because of the risk of choriocarcinoma, the woman receives extensive treatment. Therapy includes baseline chest X-ray to detect lung metastasis, plus a physical exam (including a pelvic exam). Serum B-hCG levels weekly until negative results are obtained three consecutive times, then monthly for 6 to 12 months. The woman is cautioned to avoid pregnancy during this time because the increasing B-hCG levels associated with pregnancy would cause confusion as to whether cancer had developed. If after a year B-hCG seruim titers are within normal levels, a normal pregnancy can be achieved.
The nurse is comforting and listening to a young couple who just suffered a miscarriage. When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality Explanation: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done, and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein Explanation: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.
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 absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, and 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 client at 34 weeks gestation has reported to the hospital in labor. The following is documented on history and physical assessment: No rupture of membranes, mild cramping, no bleeding Reassurring pattern on fetal heart monitor Cervix is dilated 3 cm, effacement 30%. The nurse anticipates which treatment plan?
Admission to the hospital, bed rest, and a tocolytic agent Explanation: Preterm labor is labor that occurs before the end of week 37 of gestation. It is always potentially serious because if it results in the infant's birth, the infant will be immature. Medical attempts can be made to stop labor if the fetal membranes have not ruptured, fetal distress is absent, there is no evidence that bleeding is occurring, the cervix is not dilated more than 4 to 5 cm, and effacement is not more than 50%. A woman who is in preterm labor is usually first admitted to the hospital and placed on bed rest to relieve the pressure of the fetus on the cervix. Tocolytic agents are drugs used to halt labor.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis Explanation: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.
The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?
Baby developing postbirth jaundice Explanation: The infant and mother have ABO incompatibility. The result is a development of antibodies and breaking down of the blood, resulting in jaundice in the infant after delivery. The mixing of some fetal blood with maternal blood during the amniocentesis would not cause placental abruption or preterm birth. Hemolytic anemia is caused by Rh incompatibility. ABO incompatibility will cause hemolytic disease.
A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?
Bed rest to maintain pregnancy as long as possible Explanation: At 22 weeks' gestation, the fetus is not viable. The woman would be placed on total bed rest with every attempt made to halt any further progression of dilatation of the cervix. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.
A woman in her 20s has experienced a 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 spontaneous 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 miscarriage since she was only 10 weeks pregnant and early miscarriage occurs before 12 weeks.
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion but the cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action should the LPN prioritize?
Consult with the RN about offering the client a chance to speak with a psychiatrist. Explanation: The client is experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy and need to be monitored. Encouraging the client to continue to share her feelings would be helpful, but it is not the best option offered. Contacting the hospital's psychiatry department is not within the province of the LPN to act on his or her own. Sharing the information with the physician is appropriate after apprising the RN of the situation, but the scenario described does not indicate that you have the client's permission to share this information with the client's family.
A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?
Dark red, "clumpy" vaginal discharge Explanation: Women with hydatidiform mole ("molar pregnancy") often pass blood clots or watery brown/dark red discharge from the vagina in the first trimester. If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.
Current research indicates that supplementation with what before pregnancy may reduce the risk of placental abruption?
Folic acid Explanation: New research indicates that folic acid supplementation before or during pregnancy reduces the risk of placental abruption. Neither supplementation with vitamin C, iron, nor calcium is associated with a decreased risk for placental abruption.
A 25-week-gestation client presents with a blood pressure of 152/99, pulse 78, no edema, and urine negative for protein. What would the nurse do next?
Notify the health care provider Explanation: The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.
A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption?
Onset of vaginal bleeding was sudden and painful Explanation: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption. The other findings are consistent with a diagnosis of placenta previa.
The nurse understands the need to be aware of the potential of bleeding disorders in her pregnant clients. Which disorder should she be aware of that occurs in the second trimester?
Placenta previa Explanation: Second trimester bleeding usually results from placenta previa, where the placenta lies either partially or completely over the cervical os. The pregnant client begins to experience vaginal bleeding of bright, red blood. Spontaneous abortion, hydatidaform mole and ectopic pregnancy occur in the first trimester and cervical insufficiency is not a bleeding disorder.
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta Explanation: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.
A prenatal client who is 6 weeks' gestation calls the clinic to report vaginal bleeding. For what concern will the nurse further assess the client?
Spontaneous abortion Explanation: Bleeding early in the pregnancy has several causes, including a spontaneous abortion (often referred to as a miscarriage). The other concerns would not be indicated by early pregnancy bleeding. Braxton Hicks would be indicated by contractions (but would be unexpected and concerning at this time). Urinary tract infection would be indicated by buring with urination, frequency, pain.
The nurse is caring for a woman at 32 weeks gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client?
Tachycardia Explanation: Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision (halos around lights), or sweating. Magnesium sulfate may cause sweating.
A client is 20 weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?
The client has pink vaginal discharge and pelvic pressure. Explanation: Cervical dilatation usually occurs painlessly, and often the first symptom is pink vaginal discharge or increased pelvic pressure, which then is followed by rupture of membranes and discharge of the amniotic fluid. The other answers are nonthreatening signs and symptoms.
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?
Twin-to-twin transfusion syndrome (TTTS) Explanation: When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.
The obstetric nurse is caring for a pregnant client who has been diagnosed with hydatidiform mole. What assessment should the nurse prioritize?
Vaginal bleeding Explanation: Molar pregnancies constitute a major risk factor for vaginal bleeding. The client does not normally have an increased risk for nausea, pain, or hypertension.
The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?
a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria Explanation: The nurse should call the at-risk 35-year-old client first. She is 21 weeks and has symptoms (blurred vision) of preeclampsia. She also had an increase of protein in her urine (2+) and a 15% increase in her BP. The nurse will need more information to determine if the 38-week client may be in the early stages of labor, and if the 31-week client with flank pain has a kidney infection. The client with malaise and rhinitis will need to talk to the nurse last to find out what over-the-counter medication she is able to take.
A nurse is caring for a client who just experienced a miscarriage in her first trimester. When asked by the client why this happened, which is the best response from the nurse?
abnormal fetal development Explanation: The most frequent cause of miscarriage in the first trimester of pregnancy is abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration. In other miscarriages, immunologic factors may be present or rejection of the embryo through an immune response may occur. Another common cause of early miscarriage involves implantation abnormalities. Miscarriage may also occur if the corpus luteum on the ovary fails to produce enough progesterone to maintain the decidua basalis.
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 client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?
calcium gluconate Explanation: The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?
gestational trophoblastic disease Explanation: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high HCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.
A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.
hemolysis elevated liver enzymes low platelet count Explanation: The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?
patellar reflex Explanation: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity
A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?
preeclampsia Explanation: Women with multiple gestations are at high risk for preeclampsia, preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.
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.
A woman in week 35 of her pregnancy with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?
preterm rupture of membranes followed by preterm birth Explanation: Even with precautions, in most instances of hydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are not as big of concerns as preterm birth, in this situation.
A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation. Explanation: Because RhoGAM contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of RhoGAM does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
The nurse is admitting a G3 P2 client at 38 weeks' gestation who arrived reporting painless bleeding from the vagina leading to the diagnosis of placenta previa. When questioned by the client as to what caused this, which most likely factor should the nurse point out in her answer?
previous cesarean birth Explanation: The risk of placenta previa is greatly increased when a woman has had a previous cesarean delivery due to the scarring of the endometrial lining. Maternal age over 35 years, and not just more than 30 years, is considered another risk factor. Placenta previa is more common among those living in high altitudes not among those living in coastal areas. Obesity is not recognized as a potential risk for this condition. Other risk factors can include uterine insult or injury, cocaine use, prior placenta previa, infertility treatment, multiple gestations, previous induced surgical abortion, smoking previous myomectomy to remove fibroids, short interval between pregnancies, and hypertension or diabetes.
A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
recurrent pelvic infections Explanation: In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy.
A woman in week 16 of her pregnancy calls her primary care provider's office to report that she has experienced abdominal cramping, cervical dilation, vaginal spotting, and the passing of tissue. The nurse instructs the client to bring the passed tissue to the hospital with her. What is the correct rationale for this instruction?
to determine whether gestational trophoblastic disease is present Explanation: Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. This is why it is important for any woman who begins to miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of clear fluid-filled cysts changes the diagnosis from a simple miscarriage to gestational trophoblastic disease. The client is not instructed to bring in passed tissue to determine whether infection is present or the fetus is viable or to determine the stage of development of the fetus.
After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?
"I will be sure to avoid getting pregnant for at least 1 year." Explanation: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.
The nurse is caring for a client with an ectopic pregnancy. Which symptom is a sign that the tube has ruptured?
Hypovolemic shock Explanation: An ectopic pregnancy occurs when a fertilized egg attaches somewhere outside the uterus. Symptoms appear 4 to 8 weeks after the last menstrual period and include pelvic pain and vaginal spotting. Rarely, a woman may present with late signs, such as shoulder pain or hypovolemic shock. These signs are associated with tubal rupture, which occurs when the pregnancy expands beyond the tube's ability to stretch. The other listed signs and symptoms are not associated with this complication.
A client, experiencing a threatened abortion, is concerned about losing the pregnancy and asks what she can do to help save her baby. What is the most appropriate response from the nurse?
"Restrict your physical activity to moderate bedrest." Explanation: With a threatened abortion, moderate bedrest, light activities, and supportive care are recommended. Regular physical activity may increase the chances of miscarriage. Strict bedrest is not necessary and may hide additional bleeding as it pools in the vagina, only to begin again as the woman ambulates. Activity restrictions are part of standard medical management.
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.
The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?
Vaginal bleeding and no pain Explanation: Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of abruptio placentae accompanied by severe pain. This differentiates the two conditions. Uterine contractions with vaginal mucus may be indications of the start of labor with the mucous plug being discharged. The fetal heart rate, fundal height, and contour of the abdomen are normal components that are assessed during the labor process.
A community health nurse is teaching a group of clients about the zika virus. Which statements by the clients indicate to the nurse that the teaching was effective? Select all that apply.
Zika can be transmitted by mosquitoes, sexual activity, and blood exposure. A pregnant woman with zika may have a baby with microcephaly and other congenital anomalies. It is best for men who have been exposed to zika to wait six months before attempting conception. There is no treatment for newborns with zika, but they will have supportive care based on the defects. Explanation: Zika is a mosquito-borne virus that can result in severe congenital anomalies if the mother is exposed during pregnancy or prior to conception. Men are instructed to wait at least six months from the time of possible exposure before attempting conception. Women are instructed to wait at least eight weeks, not six months. Though the virus is most frequently transmitted by mosquito bite, it can also be transmitted sexually, vertically, or by blood or organ transmission. The virus is associated with microcephaly and many other anomalies. There is no treatment specific to Zika. Supportive care is indicated to address seizures, hearing loss, spasticity, feeding difficulties, and other presenting problems.
During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition?
mild preeclampsia Explanation: A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to be mildly preeclamptic when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart. A woman has passed from mild to severe preeclampsia when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a grand-mal seizure (tonic-clonic) or coma has occurred.
The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?
"If I have changes in my vision, I will lie down and rest." Explanation: Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampisa and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia. The other choices are instructions which the client may be given to follow.
The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption are discussed. What comment validates accurate learning by the parents?
"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." Explanation: Placental abruption occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the physician will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a C-section is done. Women older than 35 are also at higher risk for developing placental abruption.
A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best?
"Please come in now for an evaluation by your health care provider." Explanation: Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs evaluated quickly and carefully. Telling the client it may be harmless or serious is a reassuring statement, but does not advice for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.
A 16-year-old client gave birth to a 12 weeks' gestation 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 and reassuring answer.
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. The client looks frightened and confused and states that she does not believe in 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." Explanation: The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments which are used to correct the situation. A threatened miscarriage becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an elective abortion or an incomplete miscarriage.
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 absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, and 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 respirator
At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdomen pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next?
Assess fetal heart rate Explanation: The presence of intense, knife-like abdomen pain with a sudden onset, a rigid and board-like abdomen, and no vaginal bleeding is evidence of a placental abruption. The next action by the nurse is to assess the fetal heart rate to determine the fetus's status. The priority is saving the life of the fetus and the mother. Inserting a urinary catheter and administering oxygen can be done once the status of the fetus is known. This client is not an appropriate candidate for an epidural at this time.
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia?
Have her blood pressure checked at every prenatal visit. Explanation: Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention— nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.
A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?
Lab work will be drawn to rule out acid-base imbalances. Explanation: Morning sickness that lasts all day and is severe is called hyperemesis gravidarum. It is much more serious than "morning sickness" and can lead to significant weight loss and electrolyte imbalance. Lab work needs to be drawn to determine the extent of electrolyte loss and acid-base balance. An ultrasound is performed but it is done to determine if the mother is experiencing a molar pregnancy. Treatment for hyperemesis gravidarum requires much more care than just rest, drinking fluids and eating crackers.
A pregnant client is admitted to a health care facility with a diagnosis of premature rupture of membranes (PROM). Which of the following tests would the nurse expect to be used to predict fetal lung maturity when the client goes into labor?
Lecithin/sphingomyelin ratio Explanation: The lecithin/sphingomyelin (L/S) ratio of the amniotic fluid helps predict the fetal lung maturity in a client with PROM who goes into labor. A reticulocyte count is used for testing sickle cell anemia. The nitrazine test aids in the diagnosis of PROM and differentiates the amniotic fluid that leaks out after PROM from the normal vaginal secretion. It does not aid in determining fetal lung maturity. A test for antiphospholipids is done in diagnosing antiphospholipids syndrome, and does not aid in determining fetal lung maturity.
A client with a multiple gestation has come to a health care facility for a regular antenatal check-up. When educating the client on pregnancy, about which complication should the nurse inform the client?
Placental dysfunction Explanation: The nurse should inform the client that placental dysfunction might occur as a complication of multiple pregnancies. Other complications of multiple pregnancies include preterm labor, hypertension, anemia, cord abnormalities, congenital anomalies, intrauterine growth restriction, and low birth weight. Hypertension, and not hypotension, is seen in multiple pregnancies. Fetal macrosomia is not seen in cases of multiple gestation. Constipation, and not diarrhea, is also seen as a complication of multiple pregnancies. This is due to the decreased functioning of the gastrointestinal system in multiple pregnancy.
A pregnant client in her 34th week of gestation is diagnosed with amnionitis due to group B streptococcus. The nurse monitors the client closely based on the understanding that the client is at risk for which of the following?
Preterm birth Explanation: The complication that may occur due to infection of pregnant clients with GBS is preterm birth. Pregnant clients infected with GBS may be asymptomatic or they may develop urinary tract infection, amnionitis and endometritis. Fetal hydrops, fetal macrosomia and fetal neural tube defects are not complications occurring with the infection of a pregnant client with GBS. Infection with parvovirus during pregnancy may result in fetal non-immune hydrops. Fetal macrosomia is seen in gestational diabetes. Fetal neural tube defect is seen due to folic acid deficiency in pregnant clients.
The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for abruptio placentae. Which assessment finding should the nurse prioritize?
Sharp fundal pain and discomfort between contractions Explanation: An abruptio placentae refers to premature separation of the placenta from the uterus. As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation. Painless vaginal bleeding and a fall in blood pressure are indicative of placenta previa. Pain in a lower quadrant and increased pulse rate are indicative of an ectopic pregnancy. Hypertension and oliguria are indicative of preeclampsia.
A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?
Threatened abortion Explanation: Spontaneous abortion occurs along a continuum: threatened, inevitable, incomplete, complete, missed. The definition of each category is related to whether or not the uterus is emptied, or for how long the products of conception are retained.
Which measure would the nurse include in the plan of care for a woman with prelabor rupture of membranes if her fetus's lungs are mature?
labor induction Explanation: With prelabor rupture of membranes (PROM) in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature. Reference:
A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?
patellar reflex Explanation: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity.
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?
use of IUD for contraception Explanation: Use of an IUD with progesterone has a known increased risk for development of ectopic pregnancies. The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple elective abortions. Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. Hormonal factors may play a role because tubal pregnancy occurs more frequently in women who take fertility drugs or who use progesterone intrauterine contraceptive devices (IUDs). A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.
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?
v\Assess the client's vital signs. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
A client suffering a miscarriage at 12 weeks' gestations is very upset that the health care provider has ordered a D&C. How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?
"This procedure is needed to adequately remove all the fetal tissue." Explanation: By this stage of pregnancy, the placenta has adhered to the uterine wall. This was not the case when the client was only 5 weeks pregnant. The total removal of the products of conception will be needed to ensure healing and prevent excessive bleeding and infection. To inform the client that the D&C is ordered by the health care provider is unprofessional and does not adequately explain the reason for the procedure. It also does not recognize the client's autonomy in choosing her health care. Informing the client that she can refuse the procedure would be unethical and could result in serious injury (including death if the client were to bleed to death). It would also be inappropriate for the nurse to imply the client will have an easier time getting pregnant again by having this procedure.
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. Explanation: A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?
Correct response: Immediate surgery Explanation: The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.
Current research indicates that supplementation with what before pregnancy may reduce the risk of placental abruption? Folic acid Explanation: New research indicates that folic acid supplementation before or during pregnancy reduces the risk of placental abruption. Neither supplementation with vitamin C, iron, nor calcium is associated with a decreased risk for placental abruption.
Folic acid Explanation: New research indicates that folic acid supplementation before or during pregnancy reduces the risk of placental abruption. Neither supplementation with vitamin C, iron, nor calcium is associated with a decreased risk for placental abruption.
A client at 36 weeks' gestation experiences vaginal bleeding. Which conditions might be the cause of the client's bleeding? Select all that apply.
Placenta previa Placental abruption Bloody show Explanation: In the third trimester, placenta previa, placental abruption, and bloody show are potential causes of vaginal bleeding. Miscarriage and ectopic pregnancy are causes of vaginal bleeding in the first trimester and would not be seen in the third trimester.