Ch 21 Nursing Care of a Family Experiencing a Sudden Pregnancy Complication

A client whose membranes have prematurely ruptured is admitted to the hospital. Which nursing intervention is a priority?

Routine monitoring of vital signs Rupture of the membranes without the onset of labor places the woman at risk for infection. The priority is to monitor temperature routinely by the completion of vital signs. Antibiotic therapy is often initiated as well, depending upon closeness of labor initiation (naturally or induced). The fetus will be monitored on a regular basis and then continuously when the labor process occurs. Urine analysis and strict intake and output are not typically completed.

The obstetric nurse is caring for a pregnant client who has been diagnosed with hydatidiform mole. What assessment should the nurse prioritize?

Vaginal bleeding Molar pregnancies constitute a major risk factor for vaginal bleeding. The client does not normally have an increased risk for nausea, pain, or hypertension.

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose?

patellar reflex A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for the patellar reflex or ankle clonus before administration is assurance the drug administration will be safe. Assessing the blood pressure, heart rate, or anxiety level would not reveal a potential magnesium toxicity.

A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client?

Lab work will be drawn to rule out acid-base imbalances. Morning sickness that lasts all day and is severe is called hyperemesis gravidarum. It is much more serious than "morning sickness" and can lead to significant weight loss and electrolyte imbalance. Lab work needs to be drawn to determine the extent of electrolyte loss and acid-base balance. An ultrasound is performed but it is done to determine if the mother is experiencing a molar pregnancy. Treatment for hyperemesis gravidarum requires much more care than just rest, drinking fluids and eating crackers.

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

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 client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?

"Purse-string sutures are placed in the cervix to prevent it from dilating." 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.

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 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?

Chromosomal defects in the fetus 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 since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

Immediate surgery The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.

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.

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 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.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching?

Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.

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.

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.

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?

"I will be sure to avoid getting pregnant for at least 1 year." After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.

The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?

"If I have changes in my vision, I will lie down and rest." Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampsia and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia. The other choices are instructions which the client may be given to follow.

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 client with a molar pregnancy is scheduled for a dilatation and curettage (D&C). The nurse is educating that client about postoperative care. The nurse will instruct the client that she will have the first serum hCG level drawn at how many hours after the D&C?

48 A serum hCG level is drawn 48 hours after the procedure to assess if the level is decreasing. Drawing it earlier does not allow adequate time for the body to begin clearing hCG after the uterus is evacuated. Drawing it much later may mask the effectiveness of the D&C procedure.

A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

A transvaginal ultrasound For any pregnant woman who presents with painless bleeding, placenta previa needs to be ruled out by either transvaginal or abdominal ultrasound. A digital cervical exam is contraindicated until placenta previa has been ruled out, as digital manipulation of placental tissue through the cervical os can cause uncontrollable bleeding. The nonstress test and electronic fetal monitoring would be utilized after the woman is stabilized and placenta previa has either been diagnosed or ruled out.

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 pregnant client at 32 weeks' gestation is treated with magnesium sulfate for seizure management. The nurse assesses which of the following for evidence of magnesium toxicity?

Absence of knee jerk response Magnesium sulfate toxicity is characterized by absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, and not frequency of micturition, is seen with magnesium sulfate toxicity. Magnesium sulfate is given to treat seizures associated with hypertension and proteinuria in pregnancy, and therefore decreases the blood pressure. It does not cause an increase in blood pressure. There is respiratory depression, and not an increased rate of respiration, with magnesium sulfate toxicity.

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

Assess the client's vital signs. 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 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

Ectopic pregnancy 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.

Current research indicates that supplementation with what before pregnancy may reduce the risk of placental abruption?

Folic acid New research indicates that folic acid supplementation before or during pregnancy reduces the risk of placental abruption. Neither supplementation with vitamin C, iron, nor calcium is associated with a decreased risk for placental abruption.

A client with a multiple gestation has come to a health care facility for a regular antenatal check-up. When educating the client on pregnancy, about which complication should the nurse inform the client?

Placental dysfunction The nurse should inform the client that placental dysfunction might occur as a complication of multiple pregnancies. Other complications of multiple pregnancies include preterm labor, hypertension, anemia, cord abnormalities, congenital anomalies, intrauterine growth restriction, and low birth weight. Hypertension, and not hypotension, is seen in multiple pregnancies. Fetal macrosomia is not seen in cases of multiple gestation. Constipation, and not diarrhea, is also seen as a complication of multiple pregnancies. This is due to the decreased functioning of the gastrointestinal system in multiple pregnancy.

A 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.

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.

The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education?

Signs of preterm labor The client with a multifetal pregnancy must be made aware of the risks posed by preterm labor. There is no corresponding increase in the risk for hypertension or blood incompatibilities. Parenting skills are secondary to physiologic needs at this point.

The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?

a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria The nurse should call the at-risk 35-year-old client first. She is 21 weeks and has symptoms (blurred vision) of preeclampsia. She also had an increase of protein in her urine (2+) and a 15% increase in her BP. The nurse will need more information to determine if the 38-week client may be in the early stages of labor, and if the 31-week client with flank pain has a kidney infection. The client with malaise and rhinitis will need to talk to the nurse last to find out what over-the-counter medication she is able to take.

A nurse is caring for a client who just experienced a 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.

The nurse is educating a group of pregnant women about risk factors associated with preterm labor. Which factor would the nurse include in the teaching? Select all that apply.

alcohol use during pregnancy lack of prenatal care victim of intimate partner violence The most common causes of preterm labor include alcohol or drug use during pregnancy, lack of or no prenatal care, victim of intimate partner violence, black race, in vitro fertilization, and a lack of support. Hyperemesis gravidarum and Asian descent are not risk factors for preterm labor.

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

calcium gluconate The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

deep tendons reflexes 2+ 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.

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition?

eclampsia This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of oxytocin is to stimulate uterine contractions to hasten birth. The client has already progressed from mild preeclampsia to severe preeclampsia, and the nurse need to follow measures to prevent advancement of the disease process. Although preeclampsia results in a high blood pressure, the scenario described does not indicate a client with hypertension.

A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?

gestational trophoblastic disease This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage.

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.

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 pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially?

normal saline For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.

A woman at 35 weeks' gestation with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?

preterm rupture of membranes followed by preterm birth Even with precautions, in most instances of hydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.

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 nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

recurrent pelvic infections 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.

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse recognizes the client is being treated for which condition?

severe preeclampsia This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of the betamethasone is to try and hasten the maturity of the fetus's lungs for birth for a preterm fetus. The scenario described does not indicate a client with hypertension, gestational diabetes, or post-term (>42 weeks) pregnancy.

A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?

use of IUD for contraception Use of an IUD with progesterone has a known increased risk for development of ectopic pregnancies. The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple elective abortions. Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. Hormonal factors may play a role because tubal pregnancy occurs more frequently in women who take fertility drugs or who use progesterone intrauterine contraceptive devices (IUDs). A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.