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

c) Upper arms d) Thighs Pg. It is generally recommended the lower abdomen be used for rotating sites for subcutaneous heparin administration. With pregnancy, however, this site is usually avoided and the injection sites are limited to the arms and thighs.

1. A pregnant client is diagnosed with deep vein thrombosis for which subcutaneous heparin is prescribed. When teaching the client how to inject the medication, which site(s) would the nurse recommended using? Select all that apply. a) Upper abdomen b) Buttocks c) Upper arms d) Thighs e) Lower abdomen

a) Elevated liver enzymes Pg. 555 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.

10. A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? a) Elevated liver enzymes b) Hyperglycemia c) Disseminated intravascular coagulation (DIC) d) Elevated platelet count

c) Folic acid Pg. 557 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.

11. Current research indicates that supplementation with what before pregnancy may reduce the risk of placental abruption? a) Calcium b) Vitamin C c) Folic acid d) Iron

b) Premature separation of the placenta Pg. 540 Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. 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.

12. 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? a) Possible fetal death or injury b) Premature separation of the placenta c) Preterm labor that was undiagnosed d) Placenta previa obstructing the cervix

d) At 28 weeks' gestation and again within 72 hours after birth Pg. 559 To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.

13. It is determined that a client'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) In the first trimester and within 2 hours of birth c) 24 hours before birth and 24 hours after birth d) At 28 weeks' gestation and again within 72 hours after birth

c) History of endometriosis Pg. 533-534 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). Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.

14. 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? a) Multiple gestation pregnancy b) High number of pregnancies c) History of endometriosis d) Use of oral contraceptives

b) Gestational trophoblastic disease Pg. 535-536 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.

15. 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? a) Pregnancy-induced depression b) Gestational trophoblastic disease c) Hyperemesis gravidarum d) Placenta previa

b) Deep tendons reflexes 2+ Pg. 545 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.

16. 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) Respiratory rate of 10 breaths/minute b) Deep tendons reflexes 2+ c) Difficulty in arousing d) Urinary output of 20 mL per hour

c) Rule out shock Pg. 534 Any time a client presents with hemorrhage, the initial nursing consideration is assessment and evaluation of shock. The next step would be to treat the shock, which could include establishing IV access and providing the client with fluids. After the client is more stable, then the source of the bleeding would be determined. In this case, that would include performing a pregnancy test to determine if the client is pregnant to rule out a placenta complication. If it is determined that the client is pregnant, the fetus would be assessed, which could include using an EFM depending on the approximate age of the fetus.

17. A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. On assessment, the nurse notes cool, clammy skin; confusion; and vital signs as the following: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize? a) Attach EFM b) Rule out pregnancy c) Rule out shock d) Establish IV access

c) Signs of preterm labor Pg. 562 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.

18. The nurse is caring for a client who has a multifetal pregnancy. What topic should the nurse prioritize during health education? a) Risk for hypertension b) Risk for blood incompatibilities c) Signs of preterm labor d) Parenting skills

b) Ectopic pregnancy Pg. 534 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.

19. 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? a) Placenta previa b) Ectopic pregnancy c) Molar pregnancy d) Healthy pregnancy

a) Contact the health care provider to report the client's feelings Pg. 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 and needs to be monitored, 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 remain silent about her feelings 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 her family.

2. An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a spontaneous abortion (miscarriage). Which action by the nurse is most appropriate? a) Contact the health care provider to report the client's feelings b) Continue to monitor the client's hyperemesis gravidarum c) Encourage the client to keep her feelings to herself d) Share the information with the client's family

d) Placenta previa Pg. The assessment findings suggest placenta previa, a bleeding condition that occurs during the last two trimesters of pregnancy. It is characterized by slight, bright red vaginal bleeding that initially 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 (abruptio placentae) is characterized by a sudden onset with concealed or visible dark vaginal bleeding, uterine tenderness and pain, 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 - 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.

20. 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 (abruptio placentae) b) Polyhydramnios c) Ruptured ectopic pregnancy d) Placenta previa

d) Vaginal bleeding Pg. 536 Molar pregnancies constitute a major risk factor for vaginal bleeding. The client does not normally have an increased risk for nausea, pain, or hypertension.

21. The obstetric nurse is caring for a pregnant client who has been diagnosed with a hydatidiform mole. What assessment should the nurse prioritize? a) Pain b) Blood pressure c) Severe nausea and vomiting d) Vaginal bleeding

c) "Please come in now for an evaluation by your health care provider" Pg. 526 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.

22. A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? a) "Lie on your left side and drink lots of water and monitor the bleeding" b) "Bleeding during pregnancy happens for many reasons, some serious and some harmless" c) "Please come in now for an evaluation by your health care provider" d) "If the bleeding lasts more than 24 hours, call us for an appointment"

d) Chromosomal defects in the fetus Pg. 561 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.

23. 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? a) Faulty implantation b) Exposure to chemicals or radiation c) Advanced maternal age d) Chromosomal defects in the fetus

a) Excessive heartburn b) Dizziness e) Blurred vision Pg. 549 The client should contact the home health nurse if any of the following occurs: increase in blood pressure; burning or frequency on urination; decrease in fetal activity or movement; headache in the forehead or posterior neck region (not a sinus headache); dizziness or visual disturbances such as blurred vision; stomach pain, excessive heartburn, or epigastric pain; decreased or infrequent urination; contractions or low back pain; easy or excessive bruising; a sudden onset of abdominal pain; or nausea and vomiting.

24. A home health care nurse is visiting a pregnant client with preeclampsia who is being managed at home. The nurse is reviewing the situations for which the client should contact the nurse. The nurse determines that the client demonstrates understanding when identifying which situation(s) as needing to be reported? Select all that apply. a) Excessive heartburn b) Dizziness c) Sinus headache d) Increased urination e) Blurred vision

b) Methotrexate Pg. 561 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.

25. Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? a) Ondansetron b) Methotrexate c) Oxytocin d) Promethazine

c) Admission to the hospital, bed rest, and a tocolytic agent Pg. 543 Preterm labor is labor that occurs before the end of week 37 of gestation. It is always potentially serious because if it results in the infant's birth, the infant will be immature. Medical attempts can be made to stop labor if the fetal membranes have not ruptured, fetal distress is absent, there is no evidence that bleeding is occurring, the cervix is not dilated more than 4 to 5 cm, and effacement is not more than 50%. A client who is in preterm labor is usually first admitted to the hospital and placed on bed rest to relieve the pressure of the fetus on the cervix. Tocolytic agents are drugs used to halt labor.

26. A client at 34 weeks gestation has reported to the hospital in labor. The following is documented on history and physical assessment: No rupture of membranes, mild cramping, no bleeding, reassuring pattern on fetal heart monitor, cervix dilated 3 cm, effacement 30%. The nurse anticipates which treatment plan? a) Discharge instructions including rest and increased fluids b) Admission to the hospital for continued labor and vaginal birth c) Admission to the hospital, bed rest, and a tocolytic agent d) Admission to the hospital and immediate cesarean birth

c) Placenta previa is an abnormally implanted placenta that is too close to the cervix Pg. 537-540 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.

27. 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? a) Placenta previa causes painful, dark red vaginal bleeding during pregnancy b) Placental abruption requires "watchful waiting" during labor and birth c) Placenta previa is an abnormally implanted placenta that is too close to the cervix d) Placental abruption results in painless, bright red vaginal bleeding during labor

a) "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications" Pg. 531 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.

28. 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 (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? a) "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications" b) "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out" c) "I know that it is sad but the pregnancy must be terminated to save your life" d) "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion)"

a) Clonus Pg. 553 The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, published a scale in the early 1990s that, though subjective, is used widely today. It grades reflexes from 0 to 4+. Grades 2+ and 3+ are considered normal, and grades 0 which indicates an absent reflex and 4 which indicates clonus may indicate pathology. Because these are subjective assessments, to improve communication of reflex results, condensed descriptor categories such as absent, average, brisk, or clonus should be used rather than numeric codes. A 4+ grade indicates clonus which is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms central nervous system involvement.

29. 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) Clonus b) Average c) Absent d) Brisk

c) Normal saline Pg. 304 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.

3. 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? a) Albumin b) Dextrose 5% and water c) Normal saline d) 0.45% sodium chloride

a) Have her blood pressure checked at every prenatal visit Pg. 549 Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.

30. A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? a) Have her blood pressure checked at every prenatal visit b) Take one aspirin every day c) Take a low-dose antihypertensive prophylactically d) Monitor the client for headaches or swelling on the body

d) Reflexes Pg. 553 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.

31. 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? a) Magnesium sulfate level b) Lung sounds c) Oxygen saturation d) Reflexes

c) "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" Pg. 537 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.

32. 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) "Since you are at the end of your reproductive years, it is suggested that you don't try to have any more pregnancies" b) "You may need chemotherapy, so we don't want to risk pregnancy" c) "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" d) "After a curettage procedure, it is recommended that you give your body some time to build up its stores"

c) Preeclampsia without severe features Pg. 552 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 have preeclampsia without severe features when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart and mild facial or extremity edema. A woman has progressed to preeclampsia with severe features 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 tonic-clonic seizure or coma has occurred.

33. During a routine prenatal visit, a client is found to have 1+ proteinuria and a blood pressure rise to 140/90 mm Hg with mild facial edema. The nurse recognizes that the client has which condition? a) Eclampsia b) Gestational hypertension c) Preeclampsia without severe features d) Preeclampsia with severe features

a) Elevated liver enzymes b) Low platelet count e) Hemolysis Pg. 555 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.

34. A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply. a) Elevated liver enzymes b) Low platelet count c) Hyperthermia d) Leukocytosis e) Hemolysis

c) Lab work will be drawn to rule out acid-base imbalances Pg. 304 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.

35. 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? a) Since morning sickness is a common problem for pregnant women, the nurse will suggest the woman drink more fluids and eat crackers b) The nurse will encourage the woman to lie down and rest whenever she feels ill c) Lab work will be drawn to rule out acid-base imbalances d) An ultrasound will be done to reassess the correctness of gestational dates

b) Tachycardia Pg. 552-553 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.

36. 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? a) Gastrointestinal bleeding b) Tachycardia c) Sweating d) Halos around lights

d) "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain" Pg. Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.

37. The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents? a) "If I develop this complication, I will have bright red vaginal bleeding" b) "I need a cesarean section if I develop this problem" c) "Since I am over 30, I run a much higher risk of developing this problem" d) "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain"

b) Assess fetal heart rate Pg. 540-541 The presence of intense, knife-like abdominal pain with a sudden onset, a rigid and board-like abdomen, and no vaginal bleeding is evidence of a placental abruption (abruptio placentae). The next action by the nurse is to assess the fetal heart rate to determine the fetus's status. The priority is saving the life of the fetus and the mother. Inserting a urinary catheter and administering oxygen can be done once the status of the fetus is known. This client is not an appropriate candidate for an epidural at this time.

38. At 37 weeks' gestation, a woman presents to labor and delivery complaining of intense, knife-like abdominal pain that started suddenly about 1 hour ago and has not subsided. On palpation, the abdomen is rigid and board-like and no vaginal bleeding is evident. What should the nurse do next? a) Insert a Foley catheter b) Assess fetal heart rate c) Prepare the client for an epidural d) Administer oxygen by face mask

a) Attach external monitoring equipment to record fetal heart sounds and kick counts c) Determine the time the bleeding began and about how much blood has been lost e) Obtain baseline vital signs and compare to those vital signs previously obtained Pg. 538 Assessment is a priority in the immediate care period. Determining the extent of the blood loss, obtaining vital signs and monitoring the fetus provides data. With the exception of performing a pelvic examination and placing the client in the supine position, all of the answers are appropriate immediate care measures. The nurse should never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix might tear the placenta further and initiate massive hemorrhage, which is possibly fatal to both client and child. The nurse should not place the client in the supine position for extended periods due to the possibility of supine hypotension. Left side lying is suggested.

39. A client reports bright red, painless vaginal bleeding during the 32nd week of pregnancy. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measures are initiated? Select all that apply. a) Attach external monitoring equipment to record fetal heart sounds and kick counts b) Assist the client in stirrups and perform a pelvic examination c) Determine the time the bleeding began and about how much blood has been lost d) Place the client on bed rest maintaining the supine position e) Obtain baseline vital signs and compare to those vital signs previously obtained

c) "Purse-string sutures are placed in the cervix to prevent it from dilating" Pg. 537 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.

4. 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? a) "The cervix is glued shut so no amniotic fluid can escape" b) "A cervical cap is placed so no amniotic fluid can escape" c) "Purse-string sutures are placed in the cervix to prevent it from dilating" d) "Staples are put in the cervix to prevent it from dilating"

a) Patellar reflex Pg. 553 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.

40. A pregnant client with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose? a) Patellar reflex b) Blood pressure c) Heart rate d) Anxiety level

b) Gestational hypertension, hyperemesis gravidarum, absence of FHR Pg. 536 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.

5. 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? a) Vaginal bleeding, increased hPL levels b) Gestational hypertension, hyperemesis gravidarum, absence of FHR c) Visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen d) Elevated hCG levels, enlarged abdomen, quickening

c) Amniocentesis Pg. 559 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.

6. 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? a) Biophysical profile b) Contraction test c) Amniocentesis d) Nonstress test

c) Chromosomal defects in the fetus Pg. 561 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.

7. 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? a) Exposure to chemicals or radiation b) Advanced maternal age c) Chromosomal defects in the fetus d) Faulty implantation

a) Assess the client's vital signs Pg. 534 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.

8. 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? a) Assess the client's vital signs b) Provide emotional support to the client and significant other c) Obtain a surgical consent from the client d) Administer oxygen to the client

a) Absence of knee jerk response Pg. 553 Magnesium sulfate toxicity is characterized by an absence of deep tendon reflexes like the knee jerk reflex. Urinary retention, 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.

9. 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? a) Absence of knee jerk response b) Increased blood pressure c) Increased rate of respiration d) Frequency of micturition