CH. 19
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? Maternal smoking Lack of prenatal care Chromosomal abnormality The age of the mother
Chromosomal abnormality Rationale: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. here 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 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? Administer oxygen to the client. Notify the health care provider. Reposition the client to left side. Increase the rate of IV fluids.
Reposition the client to left side. Rationale: 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 at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse? "Your spontaneous bleeding is not work-related." "It is hard to know why a woman bleeds during early pregnancy." "I can understand your need to find an answer to what caused this. Let's talk about this further." "Something was wrong with the fetus."
"I can understand your need to find an answer to what caused this. Let's talk about this further." Rationale: Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? Check deep tendon reflexes . Measure fundal height. Palpate the fundus and check fetal heart rate. Obtain a voided urine specimen and determine blood type.
Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
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 slight vaginal bleeding closed cervical os no passage of fetal tissue
strong abdominal cramping Rationale: 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 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? Healthy pregnancy Ectopic pregnancy Molar pregnancy Placenta previa
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 assessing a client at 12 weeks' gestation at a routine prenatal visit who reports something doesn't feel right. Which assessment findings should the nurse prioritize? elevated hCG levels, enlarged abdomen, quickening vaginal bleeding, increased hPL levels visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen gestational hypertension, hyperemesis gravidarum, absence of FHR
gestational hypertension, hyperemesis gravidarum, absence of FHR Rationale: The early development of gestational hypertension/preeclampsia, hyperemesis gravidarum, and the absence of FHR are suspicious for gestational trophoblastic disease. The elevated levels of hCG lead to the severe morning sickness. There is no fetus, so FHR, quickening, and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased.
A pregnant client at 24 weeks' gestation arrives in the office and reports that her feet and legs are swelling. During a client evaluation, the nurse notes that she can elicit a 4-mm skin depression that disappears in 10 to 15 seconds. The client is considered at risk for preeclampsia. What additional assessment would be beneficial for the nurse to complete? weight gain urine culture complete blood count fundal height
weight gain Rationale: Although edema is not a cardinal sign of preeclampsia, weight should be monitored frequently to identify sudden gains in a short time span. A urine culture is not indicated but urine would be checked for protein. A complete blood count may be done to evaluate the woman's status but would provide little information about the client's risk for preeclampsia. Fundal height is a routine assessment completed at each visit.
The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia, severe preeclampsia and eclampsia. The nurse suspects preeclampsia based on which finding? BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation BP of 130/90 mm Hg on three occasions 3 hours apart BP of 160/110 mm Hg on two occasions after 28 weeks' gestation BP of 120/90 mm Hg on three occasions after 20 weeks' gestation
BP of 140/90 mm Hg last week and at current visit after 20 weeks' gestation Rationale: Gestational hypertension is diagnosed when systolic blood pressure is over 140 mm Hg and/or diastolic pressure is over 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. Severe preeclampsia (i.e., preeclampsia with severe features) may develop suddenly or within days and bring with it high blood pressure of more than 160/110 mm Hg, cerebral and visual symptoms, and pulmonary edema.
A woman in her 20s has experienced a spontaneous abortion (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 miscarriage in the first trimester is related to which factor? Exposure to chemicals or radiation Advanced maternal age Chromosomal defects in the fetus Faulty implantation
Chromosomal defects in the fetus Rationale: 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 spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
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 (abruptio placentae)? Onset of vaginal bleeding was sudden and painful Fetus is in a breech position Sonogram shows the placenta covering the cervical os Uterus is soft between contractions
Onset of vaginal bleeding was sudden and painful Rationale: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.
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 Preterm labor that was undiagnosed Placenta previa obstructing the cervix Possible fetal death or injury
Premature separation of the placenta Rationale: Premature separation of the placenta sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. ( covers the opening of the cervix ) 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 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? Ectopic pregnancy Habitual abortion Cervical insufficiency Threatened abortion
Threatened abortion rationale: Spontaneous abortion (miscarriage) 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. threatened abortion is defined as vaginal bleeding before 20 weeks gestational age
A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission? performing a vaginal examination to assess the extent of bleeding helping the woman remain ambulatory to reduce bleeding assessing fetal heart tones by use of an external monitor assessing uterine contractions by an internal pressure gauge
assessing fetal heart tones by use of an external monitor Rationale: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated. DONT WANT TO DISRUPT THE PLACENTA
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 hemolysis liver enzyme elevation low platelet count
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 nurse is monitoring a client with PROM ( Premature rupture of membranes) who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? cord compression fetal distress related to hypoxia infection central nervous system (CNS) involvement
fetal distress related to hypoxia Rationale: 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. AT RISK: Meconium aspiration syndrome occurs when a newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery. 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. Meconium is the first feces, or stool, of the newborn
A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? preeclampsia placental abruption (abruptio placentae) placenta previa gestational hypertension
gestational hypertension rationale: 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); preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.
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? promote maternal D antibody formation . prevent maternal D antibody formation. stimulate maternal D immune antigens. prevent fetal Rh blood formation.
prevent maternal D antibody formation. Rationale: 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.
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? urine protein ability to sleep hemoglobin respiratory rate
respiratory rate Rationale: 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 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? "Maintain bed rest, and count the number of perineal pads used." "Come to the health care facility if uterine contractions begin." "Continue normal activity, but take the pulse every hour." "Come to the health facility with any vaginal material passed."
"Come to the health facility with any vaginal material passed." Rationale: This is a typical time in pregnancy for gestational trophoblastic disease to present. ( look like grapes) Asking the woman to bring any material passed vaginally would be important so the material can be ASSESSED for this. Gestational trophoblastic disease (GTD) is the term given to a group of rare tumors that develop during the early stages of pregnancy.
What special interventions would the nurse implement in a client who is carrying twin fetuses? Schedule non-stress tests (NST) starting at 16 weeks. Demonstrate to the client how to perform fetal movement (kick) counts after 32 weeks. Assist the physician on doing uterine ultrasounds every 2 weeks to monitor fetal size and placental information. Remind the client to monitor her intake since she does not need any more food for a multiple pregnancy than she would ingest for a singleton pregnancy.
Demonstrate to the client how to perform fetal movement (kick) counts after 32 weeks. Rationale:A woman carrying a multiple gestation needs to keep up with how her fetuses are doing, and an excellent way to do that is by doing fetal movement (kick) counts. This starts at around 32 weeks' gestation for an uncomplicated pregnancy and continues until birth. Weekly or biweekly NSTs begin after 32 weeks. Obstetrical ultrasounds are done every 4 to 6 weeks after confirmation of a multiple fetal pregnancy. The client needs to increase her intake, along with her iron and folic acid intake, to provide adequate nutrition for both fetuses.
A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which description of dependent edema is most accurate? Dependent edema leaves a small depression or pit after finger pressure is applied to a swollen area. Dependent edema occurs only in clients on bed rest. Dependent edema can be measured when pressure is applied. Dependent edema may be seen in the sacral area if the client is on bed rest.
Dependent edema may be seen in the sacral area if the client is on bed rest. Rationale: The nurse should know that dependent edema may be seen in the sacral area if the client is on bed rest. Pitting edema leaves a small depression or pit after finger pressure is applied to a swollen area and can be measured. Dependent edema may occur in clients who are both ambulatory and on bed rest.
A woman at 8 weeks' gestation is admitted for ectopic (grows outside the uterus pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy? high number of pregnancies multiple gestation pregnancy use of oral contraceptives history of endometriosis
history of endometriosis 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 abortions (elective terminations of pregnancy). Endometriosis: tissue that lines the uterus grows outside Conditions that inhibit peristalsis of the tube can result in tubal pregnancy.
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. ectopic pregnancy. placenta accrete. hydramnios.
hydatidiform mole Rationale: 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 The tumor forms as fluid-filled cysts resembling clusters of grapes.
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? Quantitative human chorionic gonadotropin (hCG) test Qualitative human chorionic gonadotropin (hCG) test Pelvic examination Abdominal ultrasound
Abdominal ultrasound Rationale: 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 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? "Staples are put in the cervix to prevent it from dilating." "The cervix is glued shut so no amniotic fluid can escape." "Purse-string sutures are placed in the cervix to prevent it from dilating." "A cervical cap is placed so no amniotic fluid can escape."
Purse-string sutures are placed in the cervix to prevent it from dilating. rationale: The cerclage, or purse string suture, is inserted into the cervix to prevent preterm cervical dilation (dilatation) and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating. cervical insufficiency: Cervical insufficiency (also called incompetent cervix) means your cervix opens (dilates) too early during pregnancy
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 gradual onset of symptoms fetal heart rate within normal range absence of pain
firm, rigid uterus on palpation Rationale: The uterus is firm-to-rigid to the touch with abruptio placentae. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. 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. It is soft and relaxed with placenta previa. ( covering the cervix) Gradual onset of symptoms is associated with placenta previa.
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? initial BP 120/80mm Hg; current BP 130/88 mm Hg initial BP 100/70 mm Hg; current BP 140/90 mm Hg initial BP 140/85 mm Hg; current BP 130/80 mm Hg initial BP 110/60 mm Hg; current BP 112/86 mm Hg
initial BP 100/70 mm Hg; current BP 140/90 mm Hg Rationale: A proteinuria of trace to 1+ and a rise in blood pressure to above 140/90 mm Hg is a concern the client may be developing preeclampsia. The blood pressures noted in the other options are not indicative of developing preeclampsia. The edema would not necessarily be indicative of preeclampsia; however, edema of the face and hands would be a concerning sign for severe preeclampsia.
