chapter 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

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. Explanation: 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 client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective? "Staples are put in the cervix to prevent it from dilating." -"The cervix is glued shut so no amniotic fluid can escape." - "Purse-string sutures are placed in the cervix to prevent it from dilating."- "A cervical cap is placed so no amniotic fluid can escape."

Purse-string sutures are placed in the cervix to prevent it from dilating." Explanation: The cerclage, or purse string suture is inserted into the cervix to prevent preterm cervical dilatation and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.

A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom is the priority concern for the nurse?

a dipstick value of 2+ for protein Explanation: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in the majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.

The clinic nurse routinely assesses all pregnant clients for signs of hypertension. Which symptoms experienced by the client would the nurse document as diagnostic signs of preeclampsia? Select all that apply. edema elevated liver enzymes blood pressure of 140/90 mm Hg +1 proteinuria

blood pressure of 140/90 mm Hg elevated liver enzymes +1 proteinuria Explanation: Clinical manifestations of preeclampsia include blood pressure elevated to 140/90 mm Hg or higher, 15% increase in baseline blood pressure, +1 proteinuria, elevated liver enzymes. Although no longer considered a diagnostic sign of preeclampsia, edema may be present.

woman with severe preeclampsia is receiving magnesium sulfate. The woman serum magnesium level is 9.0mEq/L. Which finding would the nurse most likely note? elevated liver enzymes diminished reflexes seizures serum magnesium level of 6.5 mEq/L

diminished reflexes Explanation: Diminished or absent reflexes occur when a client develops magnesium toxicity, serum levels greater than 8.0 mEq/L. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.

Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy? ondansetron promethazine methotrexate oxytocin

methotrexate Explanation: 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.

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What is the most likely cause of these symptoms? placenta previa obstructing the cervix premature separation of the placenta possible fetal death or injury preterm labor that was undiagnosed

premature separation of the placenta Explanation: Premature separation of the placenta begins with sharp fundal pain, usually followed by vaginal bleeding. Placenta previa usually produces painless 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

When assessing a pregnant woman with vaginal bleeding, the nurse would suspect a threatened abortion based on which finding? strong abdominal cramping passage of fetal tissue cervical dilation slight vaginal bleeding

slight vaginal bleeding Explanation: Slight vaginal bleeding early in pregnancy, no cervical dilation, and a closed cervical os are associated with a threatened abortion. Strong abdominal cramping is associated with an inevitable abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

A client experiences a threatened abortion. She is concerned about losing the pregnancy and asks what activity level she should maintain. What is the most appropriate response from the nurse? "Strict bedrest is necessary so as not to jeopardize this pregnancy." "There is no research evidence that I can recommend to you." "Carry on with the activity you engaged in before this happened." "Restrict your physical activity to moderate bedrest."

Restrict your physical activity to moderate bedrest." Explanation: With a threatened abortion, moderate bedrest and supportive care are recommended. Regular physical activity may increase the chances of miscarriage. Strict bedrest is not necessary. Activity restrictions are part of standard medical management.

A postpartum mother has the following lab data recorded: Rh is negative, and rubella titer is positive. What is the appropriate nursing intervention? Assess the Rh of the baby. Administer Rho(D) immune globulin within 72 hours. Administer rubella vaccine before discharge. Assess the rubella titer of the baby.

Administer Rho(D) immune globulin within 72 hours. Explanation: The rubella is a virus, and the mother has a positive titer indicating she is immune; this is important data for prenatal care and only has a bearing if the client were negative. The Rh is negative for the mother, and the infant status is unknown; to protect future pregnancies the mother should be given Rho(D) immune globulin. It would not be appropriate to administer the rubella vaccine, assess the rubella titer of the baby, or assess the Rh status of the bab

A client is 20 weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client? The client has rhinitis and epistaxis. The client has pink vaginal discharge and pelvic pressure. The client has a white vaginal discharge. The client vomited.

The client has pink vaginal discharge and pelvic pressure. Explanation: Cervical dilatation usually occurs painlessly, and often the first symptom is pink vaginal discharge or increased pelvic pressure, which then is followed by rupture of membranes and discharge of the amniotic fluid. The other answers are nonthreatening signs and symptoms.

The nurse is transcribing messages from the answering service. Which phone message should the nurse return first? a 25-year-old, 31-week G1P0 client with blood pressure of 100/80 mm Hg and left flank pain; the client's last blood pressure was 100/77 mm Hg and she had no proteinuria 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 a 20-year-old, 31-week G1P0 client with malaise and rhinitis; the client's last blood pressure was 120/80 mm Hg, and she had no proteinuria an 18-year-old, 38-week G2P1 client with intermittent cramping; the client's last blood pressure was 98/50 mm Hg, and proteinuria was 1+

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 Explanation: 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 woman who is 31 weeks pregnant presents at the emergency department with bright red vaginal bleeding. She says the onset of the bleeding was sudden and she has no pain. The nurse is most likely to assist the primary care provider or technician with which exam? an abdominal ultrasound a blood transfusion a digital cervical exam a transvaginal ultrasound

a transvaginal ultrasound Explanation: The use of a transvaginal ultrasound is the diagnostic test of choice; it is 100% accurate in prediction of placenta previa, while abdominal ultrasound is only 95% accurate. A digital cervical exam is contraindicated in this client, and the scenario described does not indicate the need for a blood transfusion

Rho(D) immune globulin will be prescribed for an Rh negative mother undergoing which test? contraction test amniocentesis biophysical profile nonstress test

amniocentesis Explanation: 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.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? monitoring uterine contractility assessing signs of shock determining the amount of funneling assessing the amount and color of the bleeding

assessing the amount and color of the bleeding Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole? painful uterine contractions and nausea dark red, "clumpy" vaginal discharge bright red painless vaginal bleeding brisk deep tendon reflexes and shoulder pain

dark red, "clumpy" vaginal discharge Explanation: If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.

A 28-year-old woman presents in the emergency department with severe abdominal pain. She has not had a normal period for 2 months, but she reports that that is not abnormal for her. She has a history of endometriosis. What might the nurse suggest to the primary care provider as a possible cause of the client's abdominal pain? placenta previa molar pregnancy ectopic pregnancy healthy pregnancy

ectopic pregnancy Explanation: Ectopic pregnancy can present with severe unilateral 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.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia Explanation: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? gestational hypertension preecalmpsia placenta previa abruptio placenta

gestational hypertension Explanation: Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Abruptio placenta (separation of the placenta from the uterine wall), placenta previa (placenta covering the cervical os), and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination there is an elevated hCG level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition? placenta previa ectopic pregnancy gestational trophoblastic disease abruption of placenta

gestational trophoblastic disease Explanation: The client is most likely experiencing gestational trophoblastic disease or a molar pregnancy. In gestational trophoblastic disease or molar pregnancy, there is an abnormal proliferation and eventual degeneration of the trophoblastic villi. The signs and symptoms of molar pregnancy include brownish vaginal bleeding, elevated hCG levels, discrepancy between the uterine size and the gestational age, and absent fetal heart sounds. Abruption of placenta is characterized by premature separation of the placenta. Ectopic pregnancy is a condition where there is implantation of the blastocyst outside the uterus. In placenta previa the placental attachment is at the lower uterine segment.

Which measure would the nurse include in the plan of care for a woman with premature rupture of membranes if her fetus's lungs are mature? administration of corticosteroids observation for signs of infection labor induction reduction in physical activity level

labor induction Explanation: With premature rupture of membranes in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature.

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 gestational hypertension eclampsia severe preeclampsia

mild preeclampsia Explanation: 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 nurse is explaining to a group of nursing students that eclampsia or seizures in pregnant women are preceded by an acute increase in maternal blood pressure. What are features of an acute increase in blood pressure? Select all that apply. proteinuria auditory hallucinations blurring of vision hypereflexia hyperglycemia

proteinuria hypereflexia blurring of vision Explanation: Eclampsia is usually preceded by an acute increase in blood pressure as well as worsening signs of multi-organ system failure seen as increasing liver enzymes, proteinuria, and symptoms such as blurred vision and hyperreflexia. Hyperglycemia and auditory hallucinations are not seen with an acute increase in maternal blood pressure.

A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting? ectopic pregnancy threatened abortion habitual abortion cervical insufficiency

threatened abortion Explanation: Spontaneous abortion occurs along a continuum: threatened, inevitable, incomplete, complete, missed. The definition of each category is related to whether or not the uterus is emptied, or for how long the products of conception are retained.

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 oral contraceptives high number of pregnancies use of IUD for contraception multiple gestation pregnancy

use of IUD for contraception Explanation: 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.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placenta and placenta previa. Which statement should the nurse include in the teaching?

"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placenta is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." Explanation: 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. Abruptio placenta 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.

A 16-year-old client gave birth to a 12 weeks' gestation fetus last week. The client has come to the office for follow-up and while waiting in an examination room notices that on the schedule is written her name and "follow-up of spontaneous abortion." The client is upset about what is written on the schedule. How can the nurse best explain this terminology? "Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy." "Abortion is a medical term for any interruption of pregnancy before a fetus is viable." "Spontaneous abortion is the medical name for a miscarriage." "Oh, that just means it was a miscarriage."

"Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy." Explanation: Abortion is a medical term for any interruption of a pregnancy before a fetus is viable, but it is better to speak of these early pregnancy losses as spontaneous abortions to avoid confusion with intentional terminations of pregnancies. The other responses are correct, but they do not provide the client with the most complete and reassuring answer.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the client's vital signs and bleeding. Monitor the fetal heart rate (FHR). Monitor the mass with transvaginal ultrasound. Monitor the client's beta-hCG level.

Monitor the client's vital signs and bleeding. Explanation: A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending abortion. Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

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

"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." Explanation: Because of the risk of choriocarcinoma, the woman receives extensive treatment. Therapy includes baseline chest X-ray to detect lung metastasis physical exam including 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 seruim titers are within normal levels, a normal pregnancy can be achieved.

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment would be most important prior to administering a new dose? patellar reflex -pulse rate -blood pressure -anxiety level

patellar reflex Explanation: A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for one of these before administration is assurance the drug administration will be safe.

A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority? Check for vaginal bleeding every 15 minutes. Confine the client to bed rest in a darkened room. Keep the client on her side so that secretions can drain from her mouth. Administer oxygen by face mask.

Confine the client to bed rest in a darkened room. Explanation: With severe preeclampsia, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures. The other interventions listed pertain to a client who has experienced a seizure and has thus progressed to eclampsia.

A pregnant client with hyperemesis gravidarum needs advice on how to minimize nausea and vomiting. Which instruction should the nurse give this client?

Eat small, frequent meals throughout the day. Explanation: The nurse should instruct the client with hyperemesis gravidarum to eat small, frequent meals throughout the day to minimize nausea and vomiting. The nurse should also instruct the client to avoid lying down or reclining for at least 2 hours after eating and to increase the intake of carbonated beverages. The nurse should instruct the client to try foods that settle the stomach such as dry crackers, toast, or soda.

Which statement by a pregnant client indicates the need for more teaching about preeclampsia? "I will weigh myself every morning after voiding before breakfast." "I will count my baby's movements twice a day." "If I have a slight headache, I'll take acetaminophen and call if unrelieved." "If I have changes in my vision, I will lie down and rest."

If I have changes in my vision, I will lie down and rest." Explanation: Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampisa and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. The other options would not indicate that more teaching about preeclampsia is indicated.

A client is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 centimeters, cervical insufficiency, and a visible amniotic sac at the cervical opening. What is the primary goal for this client at this point? give birth vaginally bed rest to maintain pregnancy as long as possible education on causes of cervical insufficiency for the future notification of social support for loss of pregnancy

bed rest to maintain pregnancy as long as possible Explanation: At 22 weeks' gestation, the fetus is not viable. The woman would be placed on bed rest, total, with every attempt made to halt any further progression of dilatation as long as possible. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.

When providing counseling on early pregnancy loss, the nurse should discuss which factor as the most common cause for spontaneous abortion? chromosomal abnormality lack of prenatal care maternal smoking the age of the mother

chromosomal abnormality Explanation: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done, and the mother should feel no fault. The nurse needs to educate the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.

A nurse is taking a history of a client of Asian ethnicity in the prenatal clinic. The client is 5 weeks' gestation and reports dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect?

gestational trophoblastic disease Explanation: This client has risk factors of a "molar" pregnancy: Asian ethnicity and nausea and vomiting at an early gestational week. 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.

A woman is admitted with a diagnosis of ectopic pregnancy. For which action would the nurse anticipate beginning preparation? bed rest for the next 4 weeks- intravenous administration of a tocolytic - immediate surgery - internal uterine monitoring

immediate surgery Explanation: Ectopic pregnancy means an embryo has implanted outside the uterus, usually in the fallopian tube. Surgery is usually necessary to remove the growing structure before the tube ruptures or repair the tube if rupture has already occurred. Bed rest will not correct the problem of an ectopic pregnancy. Administering a tocolytic is not indicated, nor is internal uterine monitoring.

The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions would the nurse most likely include? Select all that apply. obtaining baseline blood electrolyte levels maintaining NPO status for the first day or two monitoring intake and output administering antiemetic agents preparing the woman for insertion of a feeding tube

maintaining NPO status for the first day or two administering antiemetic agents obtaining baseline blood electrolyte levels monitoring intake and output Explanation: When hospitalization is necessary, oral food and fluids are withheld to allow the gut to rest. Antiemetic agents are ordered to help control nausea and vomiting. The woman is likely to be dehydrated, so the nurse would obtain baseline blood electrolyte levels and administer intravenous fluid and electrolyte replacement therapy as indicated. Once the nausea and vomiting subside, oral food and fluids are gradually reintroduced. Total parenteral nutrition or a feeding tube is used to prevent malnutrition only if the client does not improve with these interventions

A woman in week 35 of her pregnancy with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? development of eclampsia hemorrhaging preterm rupture of membranes followed by preterm birth development of gestational trophoblastic disease

preterm rupture of membranes followed by preterm birth Explanation: 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 not as big of concerns as preterm birth, in this situation

client has an Rh-negative blood type. Following the birth of her infant, the nurse administers her Rho(D) (D immune globulin). The purpose of this is to: prevent fetal RH blood formation. promote maternal D antibody formation. stimulate maternal D immune antigens. prevent maternal D antibody formation.

prevent maternal D antibody formation. Explanation: Because Rho(D) 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) does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

A client is admitted to labor and birth for management of severe preeclampsia. An IV infusion of magnesium sulfate is started. What is the primary goal for magnesium sulfate therapy?

prevent maternal seizures Explanation: The primary therapy goal for any preeclamptic client 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 its primary goal a decrease in blood pressure, a decrease in protein in the urine, nor the reversal of edema.

client is admitted to labor and birth for management of severe preeclampsia. An IV infusion of magnesium sulfate is started. What is the primary goal for magnesium sulfate therapy? decrease protein in urine prevent maternal seizures decrease blood pressure reverse edema

prevent maternal seizures Explanation: The primary therapy goal for any preeclamptic client 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 its primary goal a decrease in blood pressure, a decrease in protein in the urine, nor the reversal of edema.

The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every two hours. Why would the nurse do this? pulmonary atelectasis pulmonary hypertension pulmonary emboli pulmonary edema

pulmonary edema Explanation: In the hospital, monitor blood pressure at least every four hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every two hours. Adventitious sounds may indicate developing pulmonary edema.

When assessing a woman with an ectopic pregnancy, the nurse would suspect that the tube has ruptured based on which finding? nausea referred shoulder pain breast tenderness vaginal spotting

referred shoulder pain Explanation: Referred pain to the shoulder area indicates bleeding into the abdomen caused by phrenic nerve irritation when a tubal pregnancy ruptures. Vaginal spotting, nausea, and breast tenderness are typical findings of early pregnancy and an unruptured ectopic pregnancy.