Pregnancy Complications - Medical Conditions ATI CH 9

A nurse is preparing to teach a client who is at 20 weeks of gestation and is to undergo a prophylactic cervical cerclage. What should be included in the teaching? A. Describe the Procedure

A. Description of the Procedure: ● surgical reinforcement of the cervix with a heavy ligature (suture) that is placed submucosally around the cervix to strength it and prevent premature cervical dilation.

A nurse is caring for a client at 14 weeks of gestation who has hyperemesis gravidarum. The nurse is aware that which of the following are risk factors for the client? (Select all that apply.) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Migraine headache E. Oligohydramnios

ANS: A, B, D A. CORRECT: Obesity is a risk factor for hyperemesis gravidarum. B. CORRECT: Multifetal pregnancy is a risk factor for hyperemesis gravidarum. C. incorrEct: Maternal age less than 20 is a risk factor for hyperemesis gravidarum. D. CORRECT: Migraine headache is a risk factor for hyperemesis gravidarum. E. incorrEct: Oligohydramnios is not a risk factor for hyperemesis gravidarum.

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations fewer than 12/min B. Urinary output less than 30 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating

ANS: A, B, D A. CORRECT: A respiratory rate of less than 12/min is a sign of magnesium sulfate toxicity. B. CORRECT: Urinary output of less than 30 mL/hr is a sign of magnesium sulfate toxicity. C. incorrEct: The absence of patellar deep-tendon reflexes is a sign of magnesium sulfate toxicity. D. CORRECT: Decreased level of consciousness is a sign of magnesium sulfate toxicity. E. incorrEct: Flushing and sweating are adverse effects of magnesium sulfate but are not signs of toxicity.

What are the characteristics of Gestational Hypertension?

Begins after the 20th week of pregnancy Elevated blood pressure =/>140/90 mm Hg -Recorded at least twice, 4 to 6 hr apart, within a 1-week period. No proteinuria. BP returns to baseline by 6 wks postpartum. *Presence of edema is no longer considered in the definition of hypertensive disease of pregnancy.

Hyperemesis gravidarum

Excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis. Hyperemesis gravidarum may be associated with altered thyroid function. There is a risk to the fetus for intrauterine growth restriction (IUGR) or preterm birth if the condition persists.

Gestational Diabetes Mellitus (GDM)

Gestational diabetes mellitus is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should fall between 70 and 110 mg/dL. ● Symptoms of diabetes mellitus may disappear a few weeks following delivery. However, approximately 50% of women will develop diabetes mellitus within 5 years.

What are the risk factors for Cervical Insufficiency?

History of cervical trauma (previous lacerations, excessive dilations, and curettage for biopsy) Short labors Pregnancy loss in early gestation Advanced cervical dilation at earlier weeks of gestation In utero, exposure to diethylstilbestrol (ingested by the client's mother during pregnancy) Congenital structural defects of the uterus or cervix

Gestational Hypertension (GH)

Hypertensive disease in pregnancy is divided into clinical subsets of the disease based on end-organ effects and progresses along a continuum from mild gestational hypertension, mild and severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Vasospasm contributing to poor tissue perfusion is the underlying mechanism for the manifestations of pregnancy hypertensive disorders.

What signs and symptoms should the nurse be aware of for Cervical Insufficiency?

Increase in pelvic pressure or urge to push Pink-stained vaginal discharge or bleeding Possible gush of fluid (rupture of membranes) Uterine contractions with the expulsion of the fetus Postoperative (cerclage) monitoring for uterine contractions, rupture of membranes, and signs of infection

Anemia in pregnancy

Iron-deficiency anemia occurs during pregnancy due to inadequacy in maternal iron stores and consuming insufficient amounts of dietary iron.

What information should the nurse plan to teach the client regarding an incompetent cervix?

Teach the patient about signs and symptoms to report to the provider for preterm labor: rupture of membranes, infection, strong contractions less than 5 min apart, severe perineal pressure, and an urge to push. Instruct the client about using the home uterine activity monitor to evaluate uterine contractions. Arrange for the client to follow up with a home health agency for close observation and supervision. Plan for removal of the cerclage around 37 weeks of gestation.

Which diagnostic procedures are used for Cervical Insufficiency?

Ultrasound Cervical Cerclage ■ An ultrasound showing a short cervix (less than 25 mm in length), the presence of cervical funneling (beaking), or effacement of the cervical os indicates reduced cervical competence. ■ Prophylactic cervical cerclage is the surgical reinforcement of the cervix with a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature cervical dilation. Best results occur if this is done before 23 to 24 weeks of gestation. The cerclage is removed at 37 weeks of gestation or when spontaneous labor occurs.

What nutritional information would be included in the discharge instructions for a patient with hyperemesis gravidarum?

■ Advance the client to clear liquids after 24 hr if no vomiting. ■ Advance the client's diet, as tolerated, with frequent, small meals. Start with dry toast, crackers, or cereal; then move to a soft diet; and finally to a normal diet as tolerated. ■ In severe cases, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition (TPN) may be considered

Which diagnostic procedures would the nurse anticipate for a patient with GDM?

■ Biophysical profile to ascertain fetal well-being ■ Amniocentesis with alpha-fetoprotein ■ Nonstress test to assess fetal well-being

A nurse is caring for a patient with Hyperemesis Gravidarum. What assessment findings would the nurse observe and document for a patent with this condition?

■ Excessive vomiting for prolonged periods and diarrhea ■ Dehydration with possible electrolyte imbalance ■ Weight loss ■ Increased pulse rate ■ Decreased blood pressure ■ Poor skin turgor and dry mucous membranes

What are the laboratory findings for Iron-deficiency anemia during pregnancy?

■ Hgb less than 11 mg/dL in the first and third trimesters and less than 10.5 mg/dL in the second trimester ■ Hct less than 33%

What assessment data would the nurse recognize as relating to Gestational Diabetes Mellitus?

■ Hypoglycemia (nervousness, headache, weakness, irritability, hunger, blurred vision, tingling of mouth or extremities) ■ Hyperglycemia (thirst, nausea, abdominal pain, frequent urination, flushed dry skin, fruity breath) ■ Hypoglycemia ■ Shaking ■ Clammy pale skin ■ Shallow respirations ■ Rapid pulse ■ Hyperglycemia ■ Vomiting ■ Excess weight gain during pregnancy

What would the nurse do first if the patient begins to experience magnesium sulfate toxicity?

■ Immediately discontinue infusion. ■ Administer antidote calcium gluconate. ■ Prepare for actions to prevent respiratory or cardiac arrest.

What information should the nurse teach to a patient with GDM?

■ Instruct the client to perform daily kick counts. ■ Educate the client about diet and exercise. ■ Instruct the client about self-administration of insulin. ■ Educate the client about the need for postpartum laboratory testing to include OGTT and blood glucose levels

What are the discharge instructions for a patient with GH?

■ Maintain the client on bed rest, and encourage side-lying position. ■ Promote diversional activities. ■ Have the client avoid foods that are high in sodium. ■ Have the client avoid alcohol and limit caffeine. ■ Instruct the client to increase her fluid intake to 8 glasses/day. ■ Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■ Maintain a patent airway in the event of a seizure. ■ Administer antihypertensive medications as prescribed.

What laboratory tests and findings are related to GDM?

■ Routine urinalysis with glycosuria ■ A glucola screening test/1-hr glucose tolerance test (50 g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 28 weeks of gestation - fasting not necessary; a positive blood glucose screening is 130 to 140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test [OGTT] is indicated) ■ An OGTT (following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing; a fasting glucose is obtained, a 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion) ■ Presence of ketones in urine is tested to assess the severity of ketoacidosis

What would the nurse anticipate seeing in the lab results for a patient experiencing hyperemesis gravidarum?

■ Urinalysis for ketones and acetones (breakdown of protein and fat) is the most important initial laboratory test. ■ Elevated urine specific gravity. ■ Chemistry profile revealing electrolyte imbalances, such as: ☐ Sodium, potassium, and chloride reduced from low intake ☐ Acidosis resulting from excessive vomiting ☐ Elevated liver enzymes ■ Thyroid test indicating hyperthyroidism. ■ Hct concentration is elevated because inability to retain fluid results in hemoconcentration.

What are the nursing consideration when administering Magnesium sulfate to a patient with GH?

■ Use an infusion control device to maintain a regular flow rate. ■ Inform the client that she may initially feel flushed, hot, and sedated with the magnesium sulfate bolus. ■ Monitor the client's blood pressure, pulse, respiratory rate, deep-tendon reflexes, level of consciousness, urinary output (indwelling urinary catheter for accuracy), presence of headache, visual disturbances, epigastric pain, uterine contractions, and FHR and activity. ■ Place the client on fluid restriction of 100 to 125 mL/hr, and maintain a urinary output of 30 mL/hr or greater. ■ Monitor the client for signs of magnesium sulfate toxicity.

What are the risk factors for Hyperemesis gravidarum?

● Maternal age younger than 20 years ● History of migraines ● Obesity ● First pregnancy ● Multifetal gestation ● Gestational trophoblastic disease or fetus with chromosomal anomaly ● Psychosocial issues and high levels of emotional stress ● Transient hyperthyroidism

Risk factors for Gestational Hypertensive Disease

● No single profile identifies risks for gestational hypertensive disorders, but some high risks include the following: ◯ Maternal age younger than 20 or older than 40 ◯ First pregnancy ◯ Morbid obesity ◯ Multifetal gestation ◯ Chronic renal disease ◯ Chronic hypertension ◯ Familiar history of preeclampsia ◯ Diabetes mellitus ◯ Rh incompatibility ◯ Molar pregnancy ◯ Previous history of GH

What are the risk factors for developing GDM?

● Obesity ● Maternal age older than 25 years ● Family history of diabetes mellitus ● Previous delivery of an infant that was large or stillborn

What objective data during a physical assessment are associated with GH?

● Objective Data ◯ Physical assessment findings ■ Hypertension ■ Proteinuria ■ Periorbital, facial, hand, and abdominal edema ■ Pitting edema of lower extremities ■ Vomiting ■ Oliguria ■ Hyperreflexia ■ Scotoma (blind spots) ■ Epigastric pain ■ Right upper quadrant pain ■ Dyspnea ■ Diminished breath sounds ■ Seizures ■ Jaundice ■ Signs of progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, and developing coagulopathies

A nurse is preparing to teach a client who is at 20 weeks of gestation and is to undergo a prophylactic cervical cerclage. What should be included in the teaching? C. Describe at least four instructions to be given to the client.

● Remain on activity restrictions/bed rest as prescribed. ● Increase hydration to promote a relaxed uterus. ● Refrain from sexual intercourse. ● Signs and symptoms to report to the provider: preterm labor, rupture of membranes, signs of infection, strong contractions less than 5 min apart, perineal pressure, and the urge to push. ● Use of home uterine activity monitor. ● Home health agency to follow up. ● Plan for removal of the cerclage at 37 weeks of gestation.

Which medications are used to treat Gestational Hypertension?

◯ Antihypertensive medications ■ Methyldopa (Aldomet). ■ Nifedipine (Adalat, Procardia). ■ Hydralazine (Apresoline, Neopresol). ■ Labetalol hydrochloride (Normodyne, Trandate). ■ Avoid ACE inhibitors and angiotensin II receptor blockers. ◯ Anticonvulsant medications ■ Magnesium sulfate. ■ Medication of choice for prophylaxis or treatment to lower blood pressure and depress the CNS.

What are the nursing care actions for a patient with GH?

◯ Assess the client's level of consciousness. ◯ Obtain pulse oximetry. ◯ Monitor the client's urine output and obtain a clean-catch urine sample to assess for proteinuria. ◯ Obtain daily weights. ◯ Monitor vital signs. ◯ Encourage lateral positioning. ◯ Perform NST and daily kick counts as prescribed. ◯ Instruct the client to monitor I&O.

What are the diagnostic procedures associated with GH?

◯ Dipstick testing of urine for proteinuria ◯ 24-hr urine collection for protein and creatinine clearance ◯ Nonstress test, contraction stress test, biophysical profile, and serial ultrasounds to assess fetal status ◯ Doppler blood flow analysis to assess fetal well-being

What are the abnormal laboratory findings that are associated with GH?

◯ Elevated liver enzymes (LDH, AST) ◯ Increased creatinine ◯ Increased plasma uric acid ◯ Thrombocytopenia ◯ Decreased Hgb ◯ Hyperbilirubinemia

What assessment data would be noted regarding Iron-deficiency anemia?

◯ Fatigue ◯ Irritability ◯ Headache ◯ Shortness of breath with exertion ◯ Palpitations ◯ Craving unusual food (pica) ■ Pallor ■ Brittle nails ■ Shortness of breath

What medications would the nurse administer to a patient with Iron-deficiency anemia during pregnancy?

◯ Ferrous sulfate (325 mg) iron supplements twice daily ☐ Instruct the client to take the supplement on an empty stomach. ☐ Encourage a diet rich in vitamin C-containing foods to increase absorption. ☐ Suggest that the client increase roughage and fluid intake in diet to assist with discomforts of constipation. ◯ Iron dextran (Imferon) ■ Used in the treatment of iron-deficiency anemia when oral iron supplements cannot be tolerated by the client who is pregnant.

What medications would be given to a patient with hyperemesis gravidarum?

◯ Give the client IV fluids of lactated Ringer's for hydration. ◯ Give pyridoxine (Vitamin B6) and other vitamin supplements as tolerated. ◯ Use antiemetic medications cautiously for uncontrollable nausea and vomiting (ondansetron [Zofran], metoclopramide [Reglan]). ◯ Use corticosteroids to treat refractory hyperemesis gravidarum.

What lab tests would the doctor order for a patient with GH?

◯ Liver enzymes ◯ Serum creatinine, BUN, uric acid, and magnesium increase as renal function decreases ◯ CBC ◯ Clotting studies ◯ Chemistry profile

What are the nursing care actions relating to Iron-deficiency anemia during pregnancy?

◯ Prophylactic treatment using prenatal supplements with 60 mg of iron is suggested. ◯ Increase dietary intake of foods rich in iron (legumes, fruit, green, leafy vegetables, and meat). ◯ Educate the client about ways to minimize gastrointestinal adverse effects.

What are the GDM risks to the fetus?

◯ Spontaneous abortion, which is related to poor glycemic control. ◯ Infections (urinary and vaginal), which are related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism. ◯ Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage. ◯ Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing. ◯ Hypoglycemia, which is caused by overdosing in insulin, skipped or late meals, or increased exercise. ◯ Hyperglycemia, which can cause excessive fetal growth (macrosomia).

What are the signs of magnesium sulfate toxicity?

☐ Absence of patellar deep tendon reflexes ☐ Urine output less than 30 mL/hr ☐ Respirations less than 12/min ☐ Decreased level of consciousness ☐ Cardiac dysrhythmias

Which medications are used for a patient with an incompetent cervix?

Administer tocolytics prophylactically to inhibit uterine contractions.

What are the crucial components of unexpected medical conditions in pregnancy in order to ensure fetal well-being and maternal health?

Awareness Early detection Interventions

Severe Preeclampsia

BP =/> 160/100 mm Hg Proteinuria >3+ Oliguria Elevated serum creatinine >1.2 mg/dL Headache and blurred vision Hyperreflexia with possible ankle clonus Pulmonary or cardiac involvement Extensive peripheral edema Hepatic dysfunction Epigastric and right upper-quadrant pain Thrombocytopenia

Eclampsia

Eclampsia is severe preeclampsia symptoms along with the onset of seizure activity or coma. Eclampsia is usually preceded by headache, severe epigastric pain, hyperreflexia, and hemoconcentrations, which are warning signs of probable convulsions.

What types of nursing care should the RN implement for a patent with incompetent cervix?

Evaluate the client's support systems and availability of assistance if activity restrictions and/or bed rest are prescribed. Assess vaginal discharge. Monitor client reports of pressure and contractions. Check vital signs.

HELLP syndrome

HELLP syndrome is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. H - hemolysis resulting in anemia and jaundice EL - elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting LP - low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy (DIC)

Mild preeclampsia

Mild preeclampsia is GH with the addition of proteinuria of greater than 1+. Report of transient headaches may or may not occur along with episodes of irritability. Edema may be present.

What nursing care actions would be provided for a patient with hyperemesis gravidarum?

Monitor the client's I&O. Assess the client's skin turgor and mucous membranes. Monitor the client's vital signs. Monitor the client's weight. Have the client remain NPO for 24 to 48 hr.

What are the discharge instructions that should be included for a patient with an incompetent cervix?

Place the client on activity restriction/bed rest. Encourage hydration to promote a relaxed uterus. (Dehydration stimulates uterine contractions.) Advise the client to refrain from intercourse and to monitor for cervical/uterine changes.

Complications of Gestational hypertensive disease

Placental abruption Kidney failure Hepatic rupture Preterm birth Fetal and maternal death

What are some unexpected medical conditions that can occur during pregnancy?

Recurrent premature dilation of the cervix Hyperemesis gravidarum Anemia Gestational diabetes mellitus Gestational hypertension

Recurrent premature dilation of the cervix: Cervical Insufficiency (Incompetent Cervix)

Recurrent premature dilation of the cervix or cervical insufficiency is a variable condition whereby expulsion of the products of conception occurs. It is thought to be related to tissue changes and alterations in the length of the cervix.

What subjective assessment data are associated with gestational hypertension?

● Subjective Data ◯ Severe continuous headache ◯ Nausea ◯ Blurring of vision ◯ Flashes of lights or dots before the eyes

A nurse is preparing to teach a client who is at 20 weeks of gestation and is to undergo a prophylactic cervical cerclage. What should be included in the teaching? B. Identify two potential Complications:

● uterine contractions ● Rupture of membranes ● Infection

What are the medication considerations for GDM?

◯ Administer insulin as prescribed. ■ Most ORAL HYPOGLYCEMIC AGENTS are CONTRAINDICATED for gestational diabetes mellitus, but there is limited use of glyburide (DiaBeta) at this time. The provider will need to make the determination if these medications may be used.

What are the risk factors for Iron-deficiency anemia related to pregnancy?

◯ Less than 2 years between pregnancies ◯ Heavy menses ◯ Diet low in iron

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a clinical manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase (ALT) 20 IU/L D. Serum glucose 114 mg/dL

ANS: B A. incorrEct: Altered hematocrit is a clinical manifestation of hyperemesis gravidarum due to the hemoconcentration that occurs with dehydration. B. CORRECT: The presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravidarum. C. incorrEct: Liver enzymes are elevated in a client who has hyperemesis gravidarum, and this finding is within the expected reference range. D. incorrEct: Decreased serum glucose is anticipated in a client who has hyperemesis gravidarum, and this result is within the expected reference range.

A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication."

ANS: C - A diet with increased vitamin C improves the absorption of ferrous sulfate. A. incorrEct: Ferrous sulfate should be taken on an empty stomach. B. incorrEct: Ferrous sulfate is not compatible with dairy products or juices and should be taken with water. C. CORRECT: A diet with increased vitamin C improves the absorption of ferrous sulfate. D. incorrEct: Although a diet of calcium-rich foods is appropriate for the client during pregnancy, it does not improve the effectiveness of ferrous sulfate.

A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine (Adalat) B. Pyridoxine (vitamin B6) C. Ferrous sulfate D. Calcium gluconate

ANS: D - Calcium gluconate is the antidote for magnesium sulfate. A. incorrEct: Nifedipine is an antihypertensive medication that may be administered to women who have gestational hypertension. B. incorrEct: Pyridoxine (vitamin B6) is a vitamin supplement prescribed for clients who have hyperemesis gravidarum. C. incorrEct: Ferrous sulfate is a medication used in the treatment of iron deficiency anemia. D. CORRECT: Calcium gluconate is the antidote for magnesium sulfate.