Ch. 71 Care of Pts with Gynecologic Disorders
Four women phone the gynecology clinic about having new-onset vaginal bleeding. Which call does the RN decide to return first? A 23-year-old using medroxyprogesterone acetate (Depo-Provera) A 34-year-old with a history of multiple leiomyomas A 48-year-old who had an endocervical curettage yesterday A 62-year-old with no previous gynecologic problems
A 62-year-old with no previous gynecologic problems **Vaginal bleeding in a postmenopausal woman is abnormal and may be an indication of serious problems such as endometrial cancer.Bleeding in the 23-year-old using medroxyprogesterone acetate (Depo-Provera), the 34-year-old with a history of multiple leiomyomas, and the 48-year-old who had endocervical curettage yesterday is not unusual. The nurse will need to follow up with these clients.
An 18-year-old female is diagnosed with possible toxic shock syndrome (TSS) and has these vital signs: T 103.2°F (39.6°C), P 124 beats/min, R 36 breaths/min, BP 84/30 mm Hg. Which primary health care provider request does the nurse implement first? Administer O2 at 6 L/min. Give cefazolin (Ancef) 500 mg IV. Infuse normal saline IV at 500 mL/hr. Obtain blood cultures × 2 sites.
Administer O2 at 6 L/min. **Administration of oxygen would be the nurse's first action. The highest priority action for clients with shock is to maintain adequate gas exchange. Remember the ABCs (Airway, Breathing, Circulation) to assist in answering this question.Infusing normal saline IV at 500 mL/hr and giving cefazolin (Ancef) 500 mg IV will need to be implemented rapidly for this client because she must be on antibiotics to fight infection and sepsis. Obtaining blood cultures will need to be implemented rapidly, prior to administration of antibiotics (cefazolin) for the best opportunity to identify the organism.
The nurse is caring for a female client with uterine leiomyoma. What is the most likely problem this client will experience as a result of this condition? Pain Constipation Infection Bleeding
Bleeding **The most likely problem for women with fibroids is the potential for prolonged or heavy bleeding.Pain is not common but may occur if the fibroid becomes twisted. Constipation may occur if fibroids are large and press on other organs. Infection is not common as a result of fibroids.
The nurse is teaching a client how to prevent vaginal inflammation and itching. What information does the nurse include? Wear snug-fitting latex undergarments to prevent chafing. Cleanse the inner labia daily with soap and water. Do not have unprotected sex with multiple partners. Monthly douching may help reduce symptoms.
Do not have unprotected sex with multiple partners. **Unprotected sex with multiple partners can lead to vaginal infection.Tight clothing, such as pantyhose or tight jeans, would be avoided because it can cause chafing. Tight clothing can also cause the vaginal area to get hot and sweaty, which can lead to infection. Encourage the client to wear breathable fabrics such as cotton and to avoid irritants or allergens in products such as laundry detergents or bath products. During a bath or shower, the inner labial mucosa would be cleansed with only water, not soap. Soap is an irritant to the sensitive skin in those areas. The use of douches or feminine hygiene sprays is not recommended because they disturb the balance of both pH and bacteria and can aggravate irritation.
A 32-year-old client has small uterine fibroids and is considering options for treatment. To assist the woman to make a decision about whether to have magnetic resonance-guided focused ultrasound or uterine artery embolization, what will the nurse determine? If the woman has had one or more children Whether the woman wants to preserve her fertility and desires to have children. The age of onset of the woman's first menstrual period The woman's risk for uterine cancer
Whether the woman wants to preserve her fertility and desires to have children. **If the woman wants to preserve her fertility, magnetic resonance-guided focused ultrasound is a good option. If the client does not desire pregnancy, then uterine artery embolization may be used.The woman's previous childbearing history, the age of menarche, and the risk for uterine cancer do not influence the decision about which of these two types of procedures are used.
A client has gynecologic cancer. Which client statement demonstrates a correct understanding of her treatment options? "Chemotherapy will be used to shrink my cancer before I have my operation." "External beam radiation therapy (EBRT) may be used after my cancer surgery." "Brachytherapy is given on an outclient basis for 4 to 6 weeks before surgery." "The purpose of brachytherapy will be to dissolve the cancer."
"External beam radiation therapy (EBRT) may be used after my cancer surgery." **EBRT may be used to treat any stage of gynecologic cancer in combination with surgery.Chemotherapy is used as palliative treatment for advanced and recurrent disease when it has spread to other parts of the body. External beam treatment, not brachytherapy, is given on an ambulatory care basis after surgery, if needed. The purpose of brachytherapy is to assist in preventing disease recurrence. Brachytherapy involves a radiologist placing an applicator within the woman's uterus through the vagina, and after checking for correct position of the applicator, the radioactive isotope is placed in the applicator and remains for several minutes.
The nurse is performing discharge teaching for a client who is recovering from a total abdominal hysterectomy (TAH). Which client statement indicates a need for clarification? "I cannot jog for 2 to 6 weeks." "I must take my temperature twice a day for the first few days after surgery." "I will need to find a new form of birth control." "I will no longer have menstrual periods."
"I will need to find a new form of birth control." **The client who has had a TAH can no longer become pregnant. Therefore, birth control is no longer necessary.The client must avoid jogging, aerobic exercise, participating in sports, or any strenuous activity for 2 to 6 weeks. The client must take her temperature twice a day for the first few days after surgery as a precaution to monitor for infection. The client will no longer have a period, although she may have some vaginal discharge for a few days after going home.
The nurse is teaching care principles to a client who plans uterus-sparing surgery to remove uterine fibroids. Which client statement indicates that further teaching is needed? "I will be able to return to my usual activities in about 2 weeks." "It is important to avoid having sexual intercourse for 3 weeks after surgery." "Probably I will be able to go home on the day of the surgery." "Fewer complications occur with this procedure than with hysterectomies."
"It is important to avoid having sexual intercourse for 3 weeks after surgery." **The client must avoid having sexual intercourse for at least 6 weeks (not 3 weeks) after the surgery.Most clients can return to their usual activities within 2 weeks of having uterus-sparing surgery for fibroids. Most clients do go home on the day of the surgery. Postoperative pain is less and complications fewer with these procedures than with routine hysterectomies.
A client had a total abdominal hysterectomy 2 days ago and is to be discharged on antibiotics. What does the nurse include in her discharge teaching about antibiotics? "After your first day at home, you can stop them if you do not have a fever." "It is important to take them as directed until they are all gone." "Stop the antibiotic if you feel nauseated because it will lose its effectiveness." "You will need to take the drug until your incision heals."
"It is important to take them as directed until they are all gone." **The client must finish her entire course of antibiotics and take them even after she has diminished signs or symptoms. This is a fundamental principle of antibiotic administration.The client would never be instructed to stop a course of antibiotics. In cases in which clients are unable to take an antibiotic (due to nausea or another problem), an alternative antibiotic will be prescribed. The client's incision would be healed by the time that the antibiotic course is completed.
A client who had an anterior colporrhaphy is being discharged. What does the nurse tell the client before her discharge? "Avoid lifting more than 25 pounds (11.3 kg)." "Do not have sexual intercourse for at least 2 weeks." "Return to the clinic in 6 weeks for suture removal." "Take a hot bath or use a moist heating pad for discomfort."
"Take a hot bath or use a moist heating pad for discomfort." **For discomfort, the client would be instructed to use heat—either a moist heating pad or warm compresses applied to the abdomen. A hot bath may also be helpful.The client must avoid lifting anything heavier than 5 pounds (2.3 kg) and avoid sexual intercourse for 6 weeks. Sutures do not need to be removed because they may be absorbable or they may fall out (slough off) as healing occurs.
A 42-year-old woman with an intramural leiomyoma (myomas or fibroids) has been taking estrogen replacement therapy for menopausal symptoms. What does the nurse tell her about estrogen replacement therapy and how it relates to her fibroids? "Estrogen will help shrink your fibroids." "Increasing the amount of estrogen you are taking will be necessary." "The fibroids may continue to grow." "Your estrogen dosage will not change."
"The fibroids may continue to grow." **The fibroids may continue to grow because of the estrogen stimulation.The client would be instructed to see her primary health care provider to monitor their growth. The client's estrogen dose will most likely need to be decreased at some point or eliminated.
A 52-year-old client has been diagnosed with endometrial (uterine) cancer. She says to the nurse, "I was told that my cancer is stage II. What does that mean?" How does the nurse respond? "It means that your cancer remains confined to your uterus." "The spread of your cancer is beyond your pelvic area." "The cancer is in your vagina or lymph node areas." "Your cancer has spread from your uterus to your cervix."
"Your cancer has spread from your uterus to your cervix." **Stage II means that the cancer now also involves the client's cervix.Cancer that remains confined to the endometrium (innermost lining) of the uterus is classified as stage I. The spread of cancer that is beyond the pelvic area is classified as stage IV cancer. Vaginal or lymph node areas of involvement indicate that the cancer is classified as stage III.
Which gynecologic clients does the charge nurse assign to an LPN/LVN? Select all that apply. A 23-year-old who is nauseated after her laparotomy and needs to receive antiemetic drugs A 34-year-old who had a total hysterectomy for invasive cervical cancer and has a blood pressure (BP) of 88/54 mm Hg A 42-year-old who had an abdominal hysterectomy whose primary health care provider wants to remove sutures at her bedside A 48-year-old who is receiving IV chemotherapy to treat stage II cervical cancer A 52-year-old who just returned to the unit following a total abdominal hysterectomy
A 23-year-old who is nauseated after her laparotomy and needs to receive antiemetic drugs A 42-year-old who had an abdominal hysterectomy whose primary health care provider wants to remove sutures at her bedside **Both the client who is nauseated after laparotomy and needs to receive antiemetic drugs and the client who had an abdominal hysterectomy and whose primary health care provider wants to remove sutures can be cared for by an LPN/LVN.The client with a total hysterectomy and low BP has a deteriorating status (dropping BP) and requires treatment that only an RN can administer. Also, the client who is receiving IV chemotherapy requires treatment that only an RN can administer. The client who has just returned from surgery must first be assessed by the RN to determine if she is stable.
Which client does the RN assess first after receiving change-of-shift report? A 45-year-old with a history of hypothyroidism who is scheduled for a hysterectomy and bladder suspension A 48-year-old who is reporting abdominal pain and light vaginal spotting after an endometrial biopsy A 50-year-old who is receiving morphine through a client-controlled analgesia (PCA) device after a hysterectomy and who rates her pain at a level 3 (0-to-10 scale) A 54-year-old with an anterior and posterior colporrhaphy who has an elevated heart rate and an oral temperature of 101.2°F (38.4°C)
A 54-year-old with an anterior and posterior colporrhaphy who has an elevated heart rate and an oral temperature of 101.2°F (38.4°C) **The client with an anterior and posterior colporrhaphy with an elevated heart rate and fever is showing signs of postoperative infection and warrants frequent assessments. This information needs to be communicated to the surgeon as soon as possible.The client with a history of hypothyroidism who is scheduled for a hysterectomy and bladder suspension, the client with abdominal pain and light vaginal spotting after an endometrial biopsy, and the client receiving morphine through a PCA device with a pain level of 3 are not unusual cases and do not require rapid intervention by the nurse.
The nurse is reviewing laboratory results on a 34-year-old client who is suspected of having endometrial (uterine) cancer. Which laboratory tests does the nurse expect to see? Select all that apply. Alpha-fetoprotein (AFP) test Cancer antigen (CA)-125 test Human chorionic gonadotropin (hCG) level Complete Blood Count (CBC) Serum electrolytes Hereditary nonpolyposis colon cancer (HNPCC) test
Alpha-fetoprotein (AFP) test Cancer antigen (CA)-125 test Human chorionic gonadotropin (hCG) level Complete Blood Count (CBC) Hereditary nonpolyposis colon cancer (HNPCC) test **Serum tumor markers to assess for metastasis include alpha-fetoprotein (AFP) and CA-125 (cancer antigen-125), both of which may be elevated when ovarian cancer is present (Pagana and Pagana, 2014). A human chorionic gonadotropin (hCG) level may be taken to rule out pregnancy before treatment for cancer begins. A complete blood count (CBC) typically shows anemia because the client has heavy bleeding. Testing for HNPCC is done if a family history is reported because a connection has been noted between HNPCC and endometrial cancer.Serum electrolytes are not routinely checked in the diagnostic process for endometrial cancer but might be performed later.
What task does the RN delegate to unlicensed assistive personnel (UAP) working on the medical-surgical unit? Inserting a catheter in a client who has a history of uterine prolapse Giving report to a receiving nurse about a client who is being transferred Assisting with a sitz bath for a client with ulcerative vulvitis Providing discharge teaching for a client who is scheduled for brachytherapy
Assisting with a sitz bath for a client with ulcerative vulvitis **Assisting with a client's sitz bath is within the UAP scope of practice and can safely be delegated.Some specially trained UAPs do catheterize clients, but a client with a uterine prolapse poses additional problems and needs to be managed by a licensed nurse. Giving report to a receiving nurse about a client who is being transferred is an interaction that would be "nurse-to-nurse." Providing discharge teaching for a client who will be having brachytherapy (intracavitary radiation) is a complex nursing action and would be done by an RN.
A client with newly diagnosed gynecologic cancer is being discharged home. Which health care team member does the nurse contact to coordinate nursing care at home for this client? Case manager Primary Health care provider Hospice Social services
Case manager **If nursing care is needed at home, the hospital nurse or case manager makes referrals to a home health care agency.The primary health care provider is not the correct team member to coordinate home care. Hospice care is provided for clients who are at the end of their lives. This type of care is not necessary (or indicated) for this client. A referral to a social service agency is needed if the client is unable to meet the financial demands of treatment and long-term care follow-up.
The nurse is teaching a client how to adapt to physical and psychological changes after surgery for ovarian cancer. What is included in the teaching plan? Select all that apply. Encouraging the use of support groups and counseling Encouraging the expression of grief and fears Offering vaginal dilators Refraining from sexual intercourse for 6 weeks after surgery. Suggesting the use of oil-based lubricants
Encouraging the use of support groups and counseling Encouraging the expression of grief and fears Refraining from sexual intercourse for 6 weeks after surgery. **Support groups such as Gilda's Club are advisable for clients with ovarian cancer because the loss of reproductive organs involves a grief reaction. Ovarian cancer particularly carries the connotation of being serious and incurable in the view of many women. The client needs to refrain from sexual intercourse for 6 weeks after surgery.The use of a vaginal dilator is not indicated. After the woman becomes sexually active, she may have a problem with vaginal dryness as the result of hormonal changes. Water-based, rather than oil-based, lubricants would be suggested.
external beam radiation to abdomen
Gently wash area Do not apply creams or lotions unless prescribed by radiation oncologist Do not wash off marking Avoid exposing area to sunlight or temperature extremes Wear soft/nonirritating clothing
The nurse is discussing transvaginal repair for pelvic organ prolapse (POP) using surgical vaginal mesh with a client who plans to have the procedure. What teaching does the nurse include? Select all that apply. Incisional care instructions Manufacturer's labeling and information Signs and symptoms of infection Statements from women who have had successful outcomes When to contact the surgeon after the procedure
Manufacturer's labeling and information Signs and symptoms of infection When to contact the surgeon after the procedure **The manufacturer's labeling and information is included so that the client has an understanding of the product, its qualifications, and the recommendations from the U.S. Food and Drug Administration (FDA). Although rare, infection is one of the possible complications, so women need to know the signs and symptoms. Clients who have had this procedure need to know when to seek help from their gynecologist/surgeon, so the nurse would include these criteria. Since 2008, client report of complications associated with the use of transvaginal mesh has required the U.S. Food and Drug Administration (2011) to release a classic report and update advising about the safety and effectiveness of the use of this product for POP. Such complications include vaginal mesh erosion, painful sexual intercourse, infection, urinary problems, bleeding, and organ perforation.No surgical incision is involved with the procedure. Statements (testimonials) from other women are not appropriate for client education.
A client is being discharged after a total abdominal hysterectomy (TAH). What principle guides the nurse in planning discharge care and teaching? Clients in their childbearing years generally adapt better. No special home equipment will be necessary for the client. Psychological reactions would be evident by discharge. The client can resume normal activities upon discharge.
No special home equipment will be necessary for the client. **Usually, no special home equipment is needed for the client who has undergone a TAH.Generally, clients adjust better to the surgery if they have completed their childbearing years. Psychological reactions can occur months to years after surgery, particularly if sexual functioning and libido are diminished. The client who has undergone a TAH would be taught about the expected physical changes, including any activity restrictions. A 2-6 week convalescent period is usually required.
Which client history places a woman at highest risk for developing endometrial (uterine) cancer? Multiparity, human papilloma virus (HPV), smoking, and African-American ethnicity Nulliparity, endometriosis, diabetes mellitus, first pregnancy at older than 20 years Nulliparity, smoking, uterine polyps, hypertension Oral contraceptive use, smoking, localized pain in the thigh
Nulliparity, smoking, uterine polyps, hypertension **Nulliparity, smoking, uterine polyps, and hypertension are all risk factors for endometrial cancer.Multiparity, HPV, smoking, and African-American ethnicity are all risk factors for cervical cancer. Nulliparity, endometriosis, diabetes mellitus, and first pregnancy at older than 30 years are all risk factors for ovarian cancer. Oral contraceptive use, smoking, and localized pain in the thigh are all risk factors for a thrombus.
The nurse is teaching a local young women's group about health promotion and maintenance measures for prevention of gynecologic cancers. Which preventive factors does the nurse stress? Select all that apply. Annual endometrial biopsy Annual human papilloma virus (HPV) vaccination Annual Papanicolaou (Pap) test Safe sex practices Well-balanced diet
Safe sex practices Well-balanced diet **Using barrier protection, especially if a woman has multiple sexual partners, is recommended. Knowing the history of partners is also a factor in having safe sex. Eating a diet that includes a variety of healthy food choices (fruits, vegetables, low-fat protein, and healthy dairy products) is known to help a woman have a healthy reproductive system.Endometrial biopsies are not routinely performed annually except when risk for the development of the disease is increased. HPV vaccination is given to young girls (and boys) in a series of three injections over a 6-month time frame. It is best administered before they become sexually active. Women need to begin screening precautions at the age of 21 years. Between ages 21 and 29 years, women need to have a Pap test every 3 years. Women between ages 30 and 65 years need to have a Pap test plus a human papilloma virus (HPV) test (co-testing) every 5 years. In the absence of co-testing, this population needs to still have a Pap test every 3 years.
A client is scheduled for a total hysterectomy with a laparoscopic vaginal approach after a diagnosis of microinvasive cervical cancer. What psychological and/or social changes does the nurse expect this client to experience? Because the surgery does not affect a visible site, altered body image issues are not as common. The client will be actively involved in her own care in the immediate postoperative period. Sexual counseling may be needed, especially if the client has doubts about her ability to feel like a woman and engage in sexual activities. The client would demonstrate reality testing and would experience a grief reaction immediately after her surgery.
Sexual counseling may be needed, especially if the client has doubts about her ability to feel like a woman and engage in sexual activities. **Sexual function may be (or feel) different after a hysterectomy. Couples may need counseling about intercourse or alternative sexual activities. The nurse assesses the need for sexual counseling by listening for cues about altered perceptions of body image and anxiety in either of the sexual partners' responses.For many women, hysterectomy can mean the loss of their femininity, so altered body image issues must be expected with the client. Hysterectomy is major surgery, so the client will be recovering for days to a week or longer. Active involvement in her self-care will be delayed until she has moved past the initial surgical procedure recovery period. Reality testing is a later step in the grief and acceptance processes experienced by women who have had hysterectomies.