Prep U chapter 19

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."

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 to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? Diminished reflexes

Diminished or absent reflexes occur when a client develops magnesium toxicity. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin? STIs

Indications for Rho(D) immune globulin include isoimmunization, ectopic pregnancy, chorionic villus sampling, amniocentesis, prenatal hemorrhage, molar pregnancy, maternal trauma, percutaneous umbilical sampling, therapeutic or spontaneous abortion, fetal death, or fetal surgery.

A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect? ensure passage of all the products of conception

Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization.

A nurse is caring for a client who just experienced a spontaneous abortion (miscarriage) in her first trimester. When asked by the client why this happened, which is the best response from the nurse? abnormal fetal development

The most frequent cause of spontaneous abortion (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.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? firm, rigid uterus on palpation

The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

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

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.

A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy? Abdominal ultrasound

An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: hydatidiform mole

Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.

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

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.

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

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.

What would be the physiologic basis for a placenta previa? Low placental implantaion

The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

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

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 mm Hg 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 (miscarriage).

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."

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 serum titers are within normal levels, a normal pregnancy can be achieved.

An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate? Contact the health care provider to report the client's feelings.

The client may be 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, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family.

A 28-year-old client and her current partner present for the first prenatal appointment with the ob/gyn. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize? Assess client for anti-D antibodies

The client should be checked for sensitization to Rh-positive blood. It is unknown if the client did have a miscarriage earlier, and if so, what the blood type was of the fetus. The risk is high for the current fetus to be affected with hemolytic disease, and this can be easily ruled out by assessing the mother for sensitization. If this screening is negative, then no further testing is required. If the father were Rh positive, then the mother be given Rho(D) immune globulin to prevent the woman from developing antibodies to the Rho(D) factor. However, if it is positive, the health care provider may order an amniocentesis to evaluate the fetus for hemolytic disease so proper treatment and monitoring may be given. It is too early to perform a direct Coombs test. It would be improper to ignore the potential of serious complications and simply continue with routine tasks and procedures at this time.

A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first? Reposition the client on the left side

The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.

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."

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 that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) 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 abortion (elective termination of pregnancy) or an incomplete miscarriage.

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

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 a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

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."

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 the material can be assessed for this.

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (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

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 dilation (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.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? methotrexate

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 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."

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 pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? strong abdominal cramping

Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply. Hemolysis low platelet count elevated liver enzymes

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 nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP? elevated lipoproteins

The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? Notify the health care provider

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.

The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause? Chromosomal abnormality

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 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

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 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)

When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.

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

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.

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition? diabetes

Approximately 18% of all women with diabetes will develop hydramnios during their pregnancy. Hydramnios occurs in approximately 2% of all pregnancies and is associated with fetal anomalies of development.

A pregnant woman is being evaluated for HELLP. The nurse reviews the client's diagnostic test results. An elevation in which result would the nurse interpret as helping to confirm this diagnosis? LDH

HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome is a variant of the preeclampsia/eclampsia syndrome. The diagnosis is based on laboratory test results, including: low hematocrit, elevated LDH, elevated AST, elevated ALT, elevated BUN, elevated bilirubin level, elevated uric acid and creatinine levels, and low platelet count. White blood cell counts are not used to evaluate for HELLP.

A nurse is reviewing the medical record of a pregnant client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition? low lying placenta

Placenta previa is currently classified with two terms: "placenta previa" and "low-lying placenta." If the placental edge is less than 2 cm from the internal os but does not cover it, the placenta is reported as low-lying. If the placental edge covers the internal os, it is labeled as a placenta previa. Placenta accreta spectrum includes three conditions. Accreta is the most common and is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle. Placenta increta occurs when the placenta invades the myometrium, and placenta percreta occurs when it has extended through the myometrium and uterine serosa and adjacent tissue.

The nurse is orientating in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. Which symptoms would the preceptor describe to the new nurse as indicative of severe preeclampsia? Select all that apply. Blood pressure above 160/110 mm Hg Nondependent edema Hyperactive deep tendon reflexes

Preeclampsia occurs when a pregnant woman develops hypertension occurring after 20 weeks' gestation and only resolves after the fetus is delivered. Preeclampsia is exhibited by 2+ or more proteinuria, nondependent edema, blood pressure greater than 140 mm Hg systolic and above 90 mm Hg diastolic, and CNS irritability demonstrated by hyperactive deep tendon reflexes. If the client has a seizure, she has moved to eclampsia. Glycosuria is not associated with preeclampsia.

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? "knife-like" abdominal pain with vaginal bleeding

The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.

A client has been diagnosed with a partial molar pregnancy. The nurse is explaining this condition. The nurse knows the teaching was effective when the client states that as a result of an error during fertilization, there are how many chromosomes in her pregnancy? 69

A normal gamete has 23 chromosomes. At fertilization, the sperm fertilizes the ovum, resulting in 23 pairs or 46 chromosomes. In a partial molar pregnancy, two sperm penetrate the ovum, resulting in a total of 69 chromosomes. A pregnancy with 47 chromosomes results in a trisomic condition such as trisomy 21 or trisomy 18.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the clients vital signs and bleeding

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 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 clients vital signs

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 at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? respiratory rate

A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin 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

Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? gestational hypertension

Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Placental abruption (abruptio placentae), a separation of the placenta from the uterine wall; placenta previa (placenta covering the cervical os); and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation? less than 37 weeks

Preterm premature rupture of membranes (PPROM) is defined as the rupture of the membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation. PROM (premature rupture of membranes) refers to a woman who is beyond 37 weeks' gestation, has presented with spontaneous rupture of the membranes, and is not in labor.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? assessing the amount and color of the bleeding

When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

A woman at 9 weeks' gestation was unable to control the nausea and vomiting of hyperemesis gravidarum through conservative measures at home. With nausea and vomiting becoming severe, the woman was omitted to the obstetrical unit. Which action should the nurse prioritize? establish IV for rehydration

With severe nausea and vomiting the client may be dehydrated upon coming to hospital for assistance, so establishing an IV line is the priority intervention. This will also allow for hydration, and if needed, the administration of an antiemetic to bypass the gastrointestinal tract. Although the nurse will explain the NPO status to the client (so that vomiting may be brought under control) and the likelihood of being placed on bed rest with bathroom privileges, these teaching are not the priority.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? grade 2

The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

A nursing instructor identifies which factor as increasing the chances of infection when coupled with prolonged labor? premature rupture of membranes

The risk for infection increases during prolonged labor particularly in association with premature rupture of membranes. The other options do not increase the risk of infection during labor