19: Essentials of Maternity, Newborn, and Women's Health Nursing 5th Edition Chapter 19

A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor at home. The nurse determines that the teaching was successful based on which statements by the woman? Select all that apply. A. "I should check my blood pressure twice a day." B. "I will weigh myself once a week." C. "I should complete a fetal kick count each day." D. "I will check my urine for protein four times a day." E. "I'll call my health care provider if I have burning when I urinate."

A. "I should check my blood pressure twice a day." C. "I should complete a fetal kick count each day." E. "I'll call my health care provider if I have burning when I urinate." The client should take her blood pressure twice daily, check and record weight daily, perform urine dipstick checks for protein twice daily, record the number of fetal kicks daily, and notify her health care provider if she experiences burning on urination.

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? A. "I will be sure to avoid getting pregnant for at least 1 year." B. "My intake of iron will have to be closely monitored for 6 months." C. "My blood pressure will continue to be increased for about 6 more months." D. "I won't use my birth control pills for at least a year or two."

A. "I will be sure to avoid getting pregnant for at least 1 year." After evacuation of trophoblastic tissue (hydatidiform mole...growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta.), 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 hydatidiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.

A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia? A. Her mother had preeclampsia during pregnancy. B. Client has a twin sister. C. Her sister-in-law had gestational hypertension. D. This is the client's second pregnancy.

A. Her mother had preeclampsia during pregnancy A family history of preeclampsia, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.

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? A. calcium gluconate B. potassium chloride C. ferrous sulfate D. calcium carbonate

A. calcium gluconate 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. S/Sx of Mag Toxicity: Hypotension, N/V, facial flushing, retention of urine, depression, and lethargy before progressing to muscle weakness, difficulty breathing, irregular heartbeat

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply. A. dark red vaginal bleeding B. insidious onset C. absence of pain D. rigid uterus E. absent fetal heart tones

A. dark red vaginal bleeding D. rigid uterus E. absent fetal heart tones Assessment findings associated with a placental abruption include a sudden onset with concealed or visible dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid uterine tone, and fetal distress or absent fetal heart tones. Insidious Onset is a gradual, vert slow onset of disease manifestations

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A. hemorrhage B. jaundice C. edema D. infection

A. hemorrhage With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage. Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Which information would the nurse use to support this suspicion? Select all that apply. A. history of diabetes B. reports of shortness of breath C. identifiable fetal parts on abdominal palpation D. difficulty obtaining fetal heart rate E. fundal height below that for expected gestational age

A. history of diabetes B. reports of shortness of breath D. difficulty obtaining fetal heart rate Hydramnios (aka Polyhydramnios) is too much amniotic fluid around the fetus. Factors such as maternal diabetes or multiple gestations place the woman at risk for hydramnios. In addition, there is a discrepancy between fundal height and gestational age, such that a rapid growth of the uterus is noted. Shortness of breath may result from over-stretching of the uterus due to the increased amount of amniotic fluid. Often, fetal parts are difficult to palpate and fetal heart rate is difficult to obtain because of the excess fluid present.

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A. "My mother lives next door and can drive me here if necessary." B. "I have a toddler and preschooler at home who need my attention." C. "I know to call my health care provider right away if I start to bleed again." D. "I realize the importance of following the instructions for my care."

B. "I have a toddler and preschooler at home who need my attention." Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result? A. 3.3 mEq/L B. 6.1 mEq/L C. 8.4 mEq/L D. 10.8 mEq/L

B. 6.1 mEq/L Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.

A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication would the nurse expect to administer, if prescribed before administering mifepristone? A. Opioid analgesic for relief of cramping B. Antiemetic to minimize nausea C. VItamin K to reduce bleeding D. Diuretic to promote fluid loss

B. Antiemetic to minimize nausea For the client receiving mifepristone, the nurse would anticipate administering an antiemetic beforehand to reduce nausea and vomiting. Acetaminophen would be useful for pain relief, not an opioid. Vitamin K or a diuretic would not be appropriate when administering mifepristone. Vitamin K would be used to counteract bleeding such as that associated with heparin administration. A diuretic would be appropriate to promote fluid excretion with fluid overload.

A client comes to the emergency department with moderate vaginal bleeding. She says, "I have had to change my pad about every 2 hours and it looks like I may have passed some tissue and clots." The woman reports that she is 9 weeks' pregnant. Further assessment reveals the following: Cervical dilation Strong abdominal cramping Low human chorionic gonadotropin (hCG) levels Ultrasound positive for products of conception The nurse suspects that the woman is experiencing which type of spontaneous abortion? A. Threatened B. Inevitable C. Incomplete D. Complete

B. Inevitable Based on the assessment findings, the woman is likely experiencing an inevitable abortion Inevitable Abortion: vaginal bleeding, rupture of membranes, cervical dilation, strong abdominal cramping, possible passage of products of conception, and ultrasound and hCG levels indicating pregnancy loss. Threatened abortion: slight vaginal bleeding, no cervical dilation or change in cervical consistency, mild abdominal cramping, close cervical os, and no passage of fetal tissue. Incomplete abortion: intense abdominal cramping, heavy vaginal bleeding and cervical dilation with passage of some products of conception. Complete abortion: a history of vaginal bleeding and abdominal pain along with passage of tissue and subsequent decrease in pain and decrease in bleeding.

A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation Recent onset of bright red vaginal bleeding, more than with previous episode No uterine contractions at present Fetal heart rate within normal range Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect? A. Placental abruption B. Placenta previa C. Ruptured ectopic pregnancy D. Polyhydramnios

B. Placenta previa The assessment findings suggest placenta previa, (occurs when a baby's placenta partially or totally covers the mother's cervix). It is characterized by slight birght red vaginal bleeding initially that stops spontaneously and then recurs later in amounts greater than the initial episode; absence of pain/contractions; soft, relaxed uterine tone; and a fetal heart rate within normal parameters. Placental abruption is characterized by a sudden onset with concealed or visible dark vaginal bleeding, uterine tenderness and pain, with a firm or rigid uterus and fetal distress. The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. If ectopic rupture or hemorrhage occurs before treatment begins, symptoms may worsen and include severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity; feelings of faintness; referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation; hypotension; marked abdominal tenderness with distention; and hypovolemic shock. Polyhydramnios is initially suspected when uterine enlargement, maternal abdominal girth, and fundal height are larger than expected for the fetus's gestational age. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Shortness of breath and uterine contractions from overstretching may occur. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present.

A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply. A. fetal bradycardia B. abdominal tenderness C. elevated maternal pulse rate D. decreased C-reactive protein levels E. cloudy malodorous fluid

B. abdominal tenderness C. elevated maternal pulse rate E. cloudy malodorous fluid Possible signs of infection associated with premature rupture of membranes include elevation of maternal temperature and pulse rate, abdominal/uterine tenderness, fetal tachycardia over 160 bpm, elevated white blood cell count and C-reactive protein levels, and cloudy, foul-smelling amniotic fluid.

A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority? A. fluid replacement B. oxygenation C. control of hypertension D. birth of the fetus

B. oxygenation As with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable.

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? A. oligohydramnios B. preeclampsia C. post-term labor D. chorioamnionitis

B. preeclampsia Women with multiple gestations are at high risk for preeclampsia, preterm labor, polyhydramnios (Excess Amniotic Fluid), hyperemesis gravidarum (Excessive N/V throughout pregnancy), anemia, and antepartal hemorrhage (bleeding occurring from 24+0 weeks of pregnancy and prior to the birth of the baby). There is no association between multiple gestations and the development of chorioamnionitis.

A nurse is reviewing an article about preterm prelabor rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply. A. high body mass index B. urinary tract infection C. low socioeconomic status D. single gestations E. smoking

B. urinary tract infection C. low socioeconomic status E. smoking High-risk factors associated with prelabor rupture of membranes (PROM) include low socioeconomic status, multiple gestation, low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.

A woman with hyperemesis gravidarum (extreme persistent N/V throughout pregnancy) asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make? A. "Make sure that anything around your waist is quite snug." B. "Try to eat three large meals a day with less snacking." C. "Drink fluids in between meals rather than with meals." D. "Lie down for about an hour after you eat."

C. "Drink fluids in between meals rather than with meals." Suggestions to minimize nausea and vomiting include avoiding tight waistbands to minimize pressure on the abdomen, eating small frequent meals throughout the day, separating fluids from solids by consuming fluids in between meals; and avoiding lying down or reclining for at least 2 hours after eating.

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate? A. "Why are you crying?" B. "Will a pill help your pain?" C. "I'm sorry you lost your baby." D. "A baby still wasn't formed in your uterus."

C. "I'm sorry you lost your baby." Telling the client that the nurse is sorry for the loss acknowledges the loss to the woman, validates her feelings, and brings the loss into reality. Asking why the client is crying is ineffective at this time. Offering a pill for the pain ignores the client's feelings. Telling the client that the baby was not formed is inappropriate and discounts any feelings or beliefs that the client has.

A nurse is teaching a pregnant woman with preterm pre-labor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching? A. "I need to keep a close eye on how active my baby is each day." B. "I need to call my doctor if my temperature increases." C. "It's okay for my husband and me to have sexual intercourse." D. "I can shower, but I shouldn't take a tub bath."

C. "It's okay for my husband and me to have sexual intercourse." The woman with pre-term pre-labor rupture of membranes should monitor her baby's activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath.

The health care provider prescribes PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which action would be most important for the nurse to do? A. Use clean technique to administer the drug. B. Keep the gel cool until ready to use. C. Maintain the client supine for 30 minutes after administration. D. Administer intramuscularly into the deltoid area.

C. Maintain the client supine for 30 minutes after administration. When PGE2 is prescribed, the gel should come to room temperature before administering it. Sterile technique should be used, and the client should remain supine for 30 minutes after administration. Rho(D) immune globulin is administered intramuscularly into the deltoid area. PGE2 induces abortion by stimulating the uterine contractions.

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? A. urinary output of 20 mL per hour B. respiratory rate of 10 breaths/minute C. deep tendons reflexes 2+ D. difficulty in arousing

C. deep tendons reflexes 2+ 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 nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions? A. maternal disease B. cervical insufficiency C. fetal genetic abnormalities D. uterine fibroids

C. fetal genetic abnormalities The causes of spontaneous abortion are varied and often unknown. The most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in first trimester, and maternal disease is more likely in the second trimester. Those occurring during the second trimester are more likely related to maternal conditions, such as cervical insufficiency, congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, use of crack cocaine, inherited and acquired thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis.

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care? A. clear liquid diet B. total parenteral nutrition C. nothing by mouth D. administration of labetalol

C. nothing by mouth Typically, on admission, the woman with hyperemesis has oral food and fluids withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms. Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may be used if the client's condition does not improve with several days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat gestational hypertension, not hyperemesis.

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? A. use of oral contraceptives for 5 years B. ovarian cyst 2 years ago C. recurrent pelvic infections D. heavy, irregular menses

C. recurrent pelvic infections 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 pregnant client with preeclampsia is being treated with intravenous magnesium sulfate. The nurse assesses the client's deep tendon reflexes and grades them as 4+. The nurse notifies the health care provider about this finding, describing them using which term to ensure accurate communication? A. Absent B. Average C. Brisk D. Clonus

D. Clonus Reflexes graded from 0 to 4+. Absent: 0 Somewhat diminished: 1+ Normal: Grades 2+ (average reflexes) and 3+ (Slightly Hyperreflexic) Clonus: 4+ which is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms central nervous system involvement.

It is determined that a client's (mom'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? A. at 32 weeks' gestation and immediately before discharge B. 24 hours before birth and 24 hours after birth C. in the first trimester and within 2 hours of birth D. at 28 weeks' gestation and again within 72 hours after birth

D. at 28 weeks' gestation and again within 72 hours after birth To prevent isoimmunization (condition that happens when a pregnant woman's blood protein is incompatible with the baby's), the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? A. hyperglycemia B. elevated platelet count C. disseminated intravascular coagulation (DIC) D. elevated liver enzymes

D. elevated liver enzymes 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 nurse is conducting an assessment of a woman who has experienced PROM (Premature Rupture Of Membranes). Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM? A. yellow-green fluid B. blue color on Nitrazine testing C. ferning D. foul odor

D. foul odor A foul odor of the amniotic fluid indicates infection. Yellow-green fluid would suggest meconium. A blue color on Nitrazine testing and Ferning indicate the presence of amniotic fluid.

A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia? A. urine protein 300 mg/24 hours B. blood pressure 150/96 mm Hg C. mild facial edema D. hyperreflexia

D. hyperreflexia Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours, and hyperreflexia. Mild facial edema is associated with mild preeclampsia.