Chapter 30: Medical-Surgical Disorders Lowdermilk: Maternity & Women's Health Care, 11th Edition

MATCHING Because most pregnant women continue their usual activities, trauma remains a common complication during pregnancy. Approximately 1 in 12 pregnancies in the United States are complicated by trauma each year. As a result of the physiologic alterations that accompany pregnancy, special considerations for the mother and fetus are necessary when trauma occurs. Match the maternal system adaptation in pregnancy with the clinical response to trauma. a. Increased oxygen consumption b. Increased heart rate c. Decreased gastric motility d. Displacement of abdominal viscera e. Increase in clotting factors 1. Decreased placental perfusion in the supine position 2. Increased risk of thrombus formation 3. Altered pain referral 4. Increased risk of acidosis 5. Increased risk of aspiration

1. ANS: B DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 2. ANS: E DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 3. ANS: D DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 4. ANS: A DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features. 5. ANS: C DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Immediate priorities for the stabilization of the pregnant woman after trauma should be identical to that of the nonpregnant client after trauma. Fetal survival depends on maternal survival, and stabilization of the mother improves the chance of fetal well-being. Trauma may affect a number of systems within the body, and being aware of normal system alterations in the pregnant woman is important for the nurse who is caring for this client. Care should be adapted according to the body system that has been injured. The effects of trauma on pregnancy are also influenced by the length of gestation, type and severity of the injuries, and the degree of disruption of uterine and fetal physiologic features.

2. Which condition would require prophylaxis to prevent subacute bacterial endocarditis (SBE) both antepartum and intrapartum? a. Valvular heart disease b. Congestive heart disease c. Arrhythmias d. Postmyocardial infarction

: A Prophylaxis for intrapartum endocarditis and pulmonary infection may be provided for women who have mitral valve prolapse. Prophylaxis for intrapartum endocarditis is not indicated for a client with congestive heart disease, underlying arrhythmias, or postmyocardial infarction. DIF: Cognitive Level: Understand REF: p. 712 TOP: Nursing Process: Implementation

MULTIPLE RESPONSE 1. Which congenital anomalies can occur as a result of the use of antiepileptic drugs (AEDs) in pregnancy? (Select all that apply.) a. Cleft lip b. Congenital heart disease c. Neural tube defects d. Gastroschisis e. Diaphragmatic hernia

: A, B, C Congenital anomalies that can occur with AEDs include cleft lip or palate, congenital heart disease, urogenital defects, and neural tube defects. Carbamazepine and valproate should be avoided if all possible; they may cause neural tube defects. Congenital anomalies of gastroschisis and diaphragmatic hernia are not associated with the use of AEDs. DIF: Cognitive Level: Understand REF: p. 725 TOP: Nursing Process: Planning

3. In caring for a pregnant woman with sickle cell anemia, the nurse must be aware of the signs and symptoms of a sickle cell crisis. What do these include? (Select all that apply.) a. Fever b. Endometritis c. Abdominal pain d. Joint pain e. Urinary tract infection (UTI)

: A, C, D Women with sickle cell anemia have recurrent attacks (crises) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when red blood cells (RBCs) assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with the sickle cell trait are usually at a greater risk for postpartum endometritis (uterine wall infection); however, this development is not likely to occur during the pregnancy and is not a sign for the disorder. Although women with sickle cell anemia are at an increased risk for UTIs, these infections are not an indication of a sickle cell crisis. DIF: Cognitive Level: Understand REF: p. 721 TOP: Nursing Process: Assessment

2. A lupus flare-up during pregnancy or early postpartum occurs in 15% to 60% of women with this disorder. Which conditions associated with systemic lupus erythematosus (SLE) are maternal risks? (Select all that apply.) a. Miscarriage b. Intrauterine growth restriction (IUGR) c. Nephritis d. Preeclampsia e. Cesarean birth

: A, C, D, E Maternal risks associated with SLE include miscarriage, nephritis, preeclampsia, and cesarean birth. IUGR is a fetal risk related to SLE. Other fetal risks include stillbirth and prematurity. DIF: Cognitive Level: Understand REF: p. 727 TOP: Nursing Process: Assessment

3. Which information should the nurse take into consideration when planning care for a postpartum client with cardiac disease? a. The plan of care for a postpartum client is the same as the plan for any pregnant woman. b. The plan of care includes rest, stool softeners, and monitoring of the effect of activity. c. The plan of care includes frequent ambulating, alternating with active range-of-motion exercises. d. The plan of care includes limiting visits with the infant to once per day.

: B Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluids. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. The woman will be on bed rest to conserve energy and to reduce the strain on the heart. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated. DIF: Cognitive Level: Understand REF: pp. 718-719 TOP: Nursing Process: Planning

9. Which information regarding the care of antepartum women with cardiac conditions is mostimportant for the nurse to understand? a. Stress on the heart is greatest in the first trimester and the last 2 weeks before labor. b. Women with class II cardiac disease should avoid heavy exertion and any activity that causes even minor symptoms. c. Women with class III cardiac disease should get 8 to 10 hours of sleep every day and limit housework, shopping, and exercise. d. Women with class I cardiac disease need bed rest through most of the pregnancy and face the possibility of hospitalization near term.

: B Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32 of gestation, when hemodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less-than-ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can perform limited normal activities with discretion, although they still need a good amount of sleep. DIF: Cognitive Level: Understand REF: p. 711 TOP: Nursing Process: Planning

12. The client makes an appointment for preconception counseling. The woman has a known heart condition and is unsure if she should become pregnant. Which is the only cardiac condition that would cause concern? a. Marfan syndrome b. Eisenmenger syndrome c. Heart transplant d. Ventricular septal defect (VSD)

: B Pregnancy is contraindicated in clients with Eisenmenger syndrome. Women who have had heart transplants are successfully having babies. However, conception should be postponed for at least 1 year after transplantation. Management of the client with Marfan syndrome during pregnancy includes bed rest, beta-blockers, and surgery before conception. VSD is usually corrected early in life and is therefore not a contraindication to pregnancy. DIF: Cognitive Level: Understand REF: p. 714 TOP: Nursing Process: Assessment

15. Bell palsy is an acute idiopathic facial paralysis, the cause for which remains unknown. Which statement regarding this condition is correct? a. Bell palsy is the sudden development of bilateral facial weakness. b. Women with Bell palsy have an increased risk for hypertension. c. Pregnant women are affected twice as often as nonpregnant women. d. Bell palsy occurs most frequently in the first trimester.

: B The clinical manifestations of Bell palsy include the development of unilateral facial weakness, pain surrounding the ears, difficulty closing the eye, and hyperacusis. The cause is unknown; however, Bell palsy may be related to a viral infection. Pregnant women are affected at a rate of three to five times that of nonpregnant women. The incidence rate peaks during the third trimester and puerperium. Women who develop Bell palsy in pregnancy have an increased risk for hypertension. DIF: Cognitive Level: Understand REF: p. 726 TOP: Nursing Process: Assessment

18. It is extremely rare for a woman to die in childbirth; however, it can happen. In the United States, the annual occurrence of maternal death is 12 per 100,000 cases of live birth. What are the leading causes of maternal death? a. Embolism and preeclampsia b. Trauma and motor vehicle accidents (MVAs) c. Hemorrhage and infection d. Underlying chronic conditions

: B Trauma is the leading cause of obstetric death in women of childbearing age. Most maternal injuries are the result of MVAs and falls. Although preeclampsia and embolism are significant contributors to perinatal morbidity, these are not the leading cause of maternal mortality. Maternal death caused by trauma may occur as the result of hemorrhagic shock or abruptio placentae. In these cases, the hemorrhage is the result of trauma, not childbirth. The wish to become a parent is not eliminated by a chronic health problem, and many women each year risk their lives to have a baby. Because of advanced pediatric care, many women are surviving childhood illnesses and reaching adulthood with chronic health problems such as cystic fibrosis, diabetes, and pulmonary disorders. DIF: Cognitive Level: Understand REF: p. 731 TOP: Nursing Process: Assessment

4. Autoimmune disorders often occur during pregnancy because a large percentage of women with an autoimmune disorder are of childbearing age. Which disorders fall into the category of collagen vascular disease? (Select all that apply.) a. Multiple sclerosis b. SLE c. Antiphospholipid syndrome d. Rheumatoid arthritis e. Myasthenia gravis

: B, C, D, E Multiple sclerosis is not an autoimmune disorder. This patchy demyelination of the spinal cord may be a viral disorder. Autoimmune disorders (collagen vascular disease) make up a large group of conditions that disrupt the function of the immune system of the body. These disorders include those listed, as well as systemic sclerosis. DIF: Cognitive Level: Comprehend REF: p. 726 TOP: Nursing Process: Assessment

6. Which important component of nutritional counseling should the nurse include in health teaching for a pregnant woman who is experiencing cholecystitis? a. Assess the woman's dietary history for adequate calories and proteins. b. Teach the woman that the bulk of calories should come from proteins. c. Instruct the woman to eat a low-fat diet and to avoid fried foods. d. Instruct the woman to eat a low-cholesterol, low-salt diet.

: C Eating a low-fat diet and avoiding fried foods is appropriate nutritional counseling for this client. Caloric and protein intake do not predispose a woman to the development of cholecystitis. The woman should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated. DIF: Cognitive Level: Apply REF: p. 728 TOP: Nursing Process: Implementation

10. A woman at 28 weeks of gestation experiences blunt abdominal trauma as the result of a fall. The nurse must closely observe the client for what? a. Alteration in maternal vital signs, especially blood pressure b. Complaints of abdominal pain c. Placental absorption d. Hemorrhage

: C Electronic fetal monitoring (EFM) tracings can help evaluate maternal status after trauma and can reflect fetal cardiac responses to hypoxia and hypoperfusion. Signs and symptoms of placental absorption include uterine irritability, contractions, vaginal bleeding, and changes in FHR characteristics. Hypoperfusion may be present in the pregnant woman before the onset of clinical signs of shock. EFM tracings show the first signs of maternal compromise, such as when the maternal heart rate, blood pressure, and color appear normal, yet the EFM printout shows signs of fetal hypoxia. Abdominal pain, in and of itself, is not the most important symptom. However, if it is accompanied by contractions, changes in the FHR, rupture of membranes, or vaginal bleeding, then the client should be evaluated for abruptio placentae. Clinical signs of hemorrhage do not appear until after a 30% loss of circulating volume occurs. Careful monitoring of fetal status significantly assists in maternal assessment, because the fetal monitor tracing works as an oximeter of internal well-being. DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Assessment

16. A pregnant woman at term is transported to the emergency department (ED) after a severe vehicular accident. The obstetric nurse responds and rushes to the ED with a fetal monitor. Cardiopulmonary arrest occurs as the obstetric nurse arrives. What is the highest priority for the trauma team? a. Obtaining IV access, and starting aggressive fluid resuscitation b. Quickly applying the fetal monitor to determine whether the fetus viability c. Starting cardiopulmonary resuscitation (CPR) d. Transferring the woman to the surgical unit for an emergency cesarean delivery in case the fetus is still alive

: C In a situation of severe maternal trauma, the systematic evaluation begins with a primary survey and the initial ABCs (airway, breathing, and circulation) of resuscitation. CPR is initiated first, followed by intravenous (IV) replacement fluid. After immediate resuscitation and successful stabilization measures, a more detailed secondary survey of the mother and fetus should be accomplished. Attempts at maternal resuscitation are made, followed by a secondary survey of the fetus. In the presence of multisystem trauma, a cesarean delivery may be indicated to increase the chance for maternal survival. DIF: Cognitive Level: Apply REF: p. 734 TOP: Nursing Process: Implementation

5. A woman with asthma is experiencing a postpartum hemorrhage. Which drug should be avoided when treating postpartum bleeding to avoid exacerbating asthma? a. Oxytocin (Pitocin) b. Nonsteroidal antiinflammatory drugs (NSAIDs) c. Hemabate d. Fentanyl

: C Prostaglandin derivatives should not be used to treat women with asthma, because they may exacerbate symptoms. Oxytocin is the drug of choice to treat this woman's bleeding; it will not exacerbate her asthma. NSAIDs are not used to treat bleeding. Fentanyl is used to treat pain, not bleeding. DIF: Cognitive Level: Analyze REF: p. 722 TOP: Nursing Process: Planning

4. A woman has experienced iron deficiency anemia during her pregnancy. She had been taking iron for 3 months before the birth. The client gave birth by cesarean 2 days earlier and has been having problems with constipation. After assisting her back to bed from the bathroom, the nurse notes that the woman's stools are dark (greenish-black). What should the nurse's initial action be? a. Perform a guaiac test, and record the results. b. Recognize the finding as abnormal, and report it to the primary health care provider. c. Recognize the finding as a normal result of iron therapy. d. Check the woman's next stool to validate the observation.

: C The nurse should recognize that dark stools are a common side effect in clients who are taking iron replacement therapy. A guaiac test would be indicated if gastrointestinal (GI) bleeding was suspected. GI irritation, including dark stools, is also a common side effect of iron therapy. Observation of stool formation is a normal nursing activity. DIF: Cognitive Level: Apply REF: p. 716 TOP: Nursing Process: Evaluation

11. Which neurologic condition would require preconception counseling, if at all possible? a. Eclampsia b. Bell palsy c. Epilepsy d. Multiple sclerosis

: C Women with epilepsy should receive preconception counseling, if at all possible. Achieving seizure control before becoming pregnant is a desirable state. Medication should also be carefully reviewed. Eclampsia may sometimes be confused with epilepsy, and Bell palsy is a form of facial paralysis; preconception counseling for either condition is not essential to care. Multiple sclerosis is a patchy demyelination of the spinal cord that does not affect the normal course of pregnancy or birth. DIF: Cognitive Level: Understand REF: p. 725 TOP: Nursing Process: Planning

7. Postoperative care of the pregnant woman who requires abdominal surgery for appendicitis includes which additional assessment? a. Intake and output (I&O) and intravenous (IV) site b. Signs and symptoms of infection c. Vital signs and incision d. Fetal heart rate (FHR) and uterine activity

: D Care of a pregnant woman undergoing surgery for appendicitis differs from that for a nonpregnant woman in one significant aspect: the presence of the fetus. Continuous fetal and uterine monitoring should take place. An assessment of I&O levels, along with an assessment of the IV site, are normal postoperative care procedures. Evaluating the client for signs and symptoms of infection is also part of routine postoperative care. Routine vital signs and evaluation of the incision site are expected components of postoperative care. DIF: Cognitive Level: Apply REF: p. 730 TOP: Nursing Process: Assessment

8. Since the gene for cystic fibrosis was identified in 1989, data can be collected for the purposes of genetic counseling for couples regarding carrier status. According to the most recent statistics, how often does cystic fibrosis occur in Caucasian live births? a. 1 in 100 b. 1 in 1000 c. 1 in 2000 d. 1 in 3200

: D Cystic fibrosis occurs in approximately 1 in 3200 Caucasian live births. 1 in 100, 1 in 1000, and 1 in 2000 occurrences of cystic fibrosis in live births are all too frequent rates. DIF: Cognitive Level: Remember REF: p. 722 TOP: Nursing Process: Assessment

13. What form of heart disease in women of childbearing years generally has a benign effect on pregnancy? a. Cardiomyopathy b. Rheumatic heart disease c. Congenital heart disease d. Mitral valve prolapse

: D Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart failure during pregnancy. Some congenital heart diseases produce pulmonary hypertension or endocarditis during pregnancy. DIF: Cognitive Level: Remember REF: p. 713 TOP: Nursing Process: Assessment

14. A pregnant woman at 33 weeks of gestation is brought to the birthing unit after a minor automobile accident. The client is experiencing no pain and no vaginal bleeding, her vital signs are stable, and the FHR is 132 beats per minute with variability. What is the nurse's highestpriority? a. Monitoring the woman for a ruptured spleen b. Obtaining a physician's order to discharge her home c. Monitoring her for 24 hours d. Using continuous EFM for a minimum of 4 hours

: D Monitoring the external FHR and contractions is recommended after blunt trauma in a viable gestation for a minimum of 4 hours, regardless of injury severity. Fetal monitoring should be initiated as soon as the woman is stable. In this scenario, no clinical findings indicate the possibility of a ruptured spleen. If the maternal and fetal findings are normal, then EFM should continue for a minimum of 4 hours after a minor trauma or a minor automobile accident. Once the monitoring has been completed and the health care provider is reassured of fetal well-being, the client may be discharged home. Monitoring for 24 hours is unnecessary unless the ERM strip is abnormal or nonreassuring. DIF: Cognitive Level: Apply REF: p. 732 TOP: Nursing Process: Planning

17. Another common pregnancy-specific condition is pruritic urticarial papules and plaques of pregnancy (PUPPP). A client asks the nurse why she has developed this condition and what can be done. What is the nurse's bestresponse? a. PUPPP is associated with decreased maternal weight gain. b. The rate of hypertension decreases with PUPPP. c. This common pregnancy-specific condition is associated with a poor fetal outcome. d. The goal of therapy is to relieve discomfort.

: D PUPPP is associated with increased maternal weight gain, increased rate of twin gestation, and hypertension. It is not, however, associated with poor maternal or fetal outcomes. The goal of therapy is simply to relieve discomfort. Antipruritic topical medications, topical steroids, and antihistamines usually provide relief. PUPPP usually resolves before childbirth or shortly thereafter. DIF: Cognitive Level: Apply REF: p. 724 TOP: Nursing Process: Planning

1. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition? a. Regular heart rate and hypertension b. Increased urinary output, tachycardia, and dry cough c. Shortness of breath, bradycardia, and hypertension d. Dyspnea, crackles, and an irregular, weak pulse

: D Signs of cardiac decompensation include dyspnea; crackles; an irregular, weak, and rapid pulse; rapid respirations; a moist and frequent cough; generalized edema; increasing fatigue; and cyanosis of the lips and nailbeds. A regular heart rate and hypertension are not generally associated with cardiac decompensation. Of the symptoms of increased urinary output, tachycardia, and dry cough, only tachycardia is indicative of cardiac decompensation. Of the symptoms of shortness of breath, bradycardia, and hypertension, only dyspnea is indicative of cardiac decompensation. DIF: Cognitive Level: Understand REF: p. 716 TOP: Nursing Process: Assessment