Maternity
The postpartum nurse has just received report on four clients. Which client should the nurse care for first?
Client who vaginally delivered a 9-lb baby 1 hour ago Rationale: The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An over distended uterus caused by a large fetus (9-lb baby) can cause uterine atony. Delivering a 7-lb baby or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.
A client with severe preeclampsia is hospitalized. What should a nurse do first to ensure her physical safety?
Institute seizure precautions Rationale: This client may become eclamptic suddenly and have a seizure; seizure precautions are necessary to keep her from injuring herself and the fetus. Decreasing environmental stimuli is important, but the client's safety should be ensured first. Administering sedatives will help reduce nervous system irritability; it will not ensure safety if the client has a seizure. Monitoring intake and output will be required when magnesium sulfate therapy is started.
At 37 weeks' gestation a client's membranes spontaneously rupture but she does not have contractions. What action is most important in the nursing plan of care for this client?
Monitoring for the presence of fever Rationale: The possibility of an ascending infection increases when membranes have ruptured and birth is not imminent; the client must be monitored for signs of infection. Preeclampsia is unrelated to spontaneous rupture of the membranes. Heavy vaginal bleeding is a sign of placenta previa, which is generally diagnosed before membranes rupture. Fetal scalp pH sampling is not indicated with spontaneous rupture of membranes; it is indicated if persistent late decelerations are noted on the fetal monitor during labor.
A couple is concerned about the risks associated with an in vitro fertilization embryo transfer (IVF-ET).Which of the following is a risk factor associated with IVF?
Tubal pregnancy Rationale: There is an increased risk of tubal pregnancy with IVF-ET. There is not an increased risk for embryonic HIV infection, congenital anomalies, or hyperemesis gravidarum with IVF-ET.
A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?
Abruptio placentae Rationale: Abruptio placentae indicates premature placental separation; the classic signs are abdominal rigidity, a tetanic uterus, and dark-red bleeding. Placenta previa occurs with a low-lying placenta and is manifested by painless bright-red bleeding. Information on cervical effacement, dilation, and station is required before the nurse can come to this conclusion. Fetal presentation is not related to the client's signs and symptoms.
When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased?
48 hours postpartum Rationale: The danger of a seizure in a woman with eclampsia subsides when postpartum diuresis has occurred, usually 48 hours after birth; however, the risk for seizures may remain for as long as 2 weeks after delivery. After birth occurs, after labor starts, and 24 hours after delivery are all too soon.
A client with type 1 diabetes who is at 39 weeks' gestation is admitted to the high-risk maternity unit. The client tells the nurse that her diabetes is under control and that she doesn't understand why she must be hospitalized. What is the best response by the nurse?
"The risk for fetal complications is highest after the 36th week of gestation." Rationale: Close monitoring is necessary because fetal death may occur in pregnant women with type 1 diabetes after 36 weeks' gestation. Death may be a result of acidosis and placental dysfunction. A cesarean birth or induction of labor may be necessary. Exercise and ambulation are needed to promote adequate circulation and prevent thromboembolism. Insulin administration is not routine; it is administered according to need. Fetal growth continues as long as placental function is intact.
A client calls the nurse-midwife in the prenatal clinic, complaining of sharp shooting pains in the lower abdomen and vaginal spotting. She is met at the emergency department of the hospital, where a diagnosis of ruptured tubal pregnancy is made. At what stage of the pregnancy does the nurse suspect the initial symptoms began?
About 6 weeks into the pregnancy Rationale: At this time the fallopian tube is unable to expand to the size of the growing products of conception. Tubal pregnancies are unable to advance to this stage because of the tube's inability to expand with the growing products of conception. The size of the fertilized egg at this time is minuscule and will cause no problem. Tubal pregnancies are unable to advance to this stage because of the tube's inability to expand with the growing products of conception.
What is the best method for the nurse to use when assessing blood loss in a client with placenta previa?
Count or weigh perineal pads. Rationale: An accurate measurement of the amount of blood loss may be obtained by counting or weighing pads. The vital signs will reflect the effects of the blood loss rather than the amount. Laboratory results demonstrate the effects of the blood loss rather than the amount. The fundus may be higher than expected because the low-lying placenta prevents the descent of the fetus into the pelvis, but the height cannot be used to estimate blood loss.
A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client?
Dyspnea Rationale: One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. This blood pressure is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated because the clot could be dislodged.
A nurse is caring for a client with placenta previa who is in labor. What action is most important for the nurse to take?
Evaluating external blood loss by counting pads Rationale: Evaluating external blood loss by counting pads will indicate whether bleeding is progressing toward maternal or fetal compromise. Attempting to insert an internal fetal monitor is contraindicated because the placenta will be disturbed; an external fetal monitor should be applied. Vaginal examinations are contraindicated because they may stimulate more bleeding if the placenta is dislodged. The height of the fundus will increase, not decrease, as blood accumulates in the uterus.
A 36-year-old primagravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, what does the nurse identify as the priority of care?
Notifying the primary health care provider about the epigastric pain, headache, and blurred vision Rationale: Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours should be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible. Because the client is receiving a central nervous system depressant, it is more likely that the fetal heart rate will be decreased. The client is usually on nothing-by-mouth status during magnesium sulfate administration, particularly with unstable clinical finding, because of the possible need for an emergency cesarean birth. Although it is important to monitor the client's respirations and to ensure that calcium gluconate (magnesium sulfate antagonist) is available, neither is the priority in a life-threatening situation.
A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the priority nursing action is:
Preparing for a cesarean birth Rationale: The lesions are probably a herpes infection, which can be fatal to the newborn if it is transmitted during a vaginal birth. Herpes is a viral infection that does not respond to antibiotics. A client in active labor will give birth vaginally, before the test results of the smear become available. Standard precautions should be used; double gloving is unnecessary.
What is the initial nursing objective for a grand multipara who has had a cesarean birth?
Prevention of hemorrhage Rationale: For grand multiparas, monitoring for failure of the uterus to contract is a priority during the postpartum period. An atonic uterus predisposes the client to bleeding. Although promotion of wound healing, prevention of wound dehiscence, and establishment of bonding are all important goals, they are not specific to grand multiparas.
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude?
The fetus may be compromised in utero. Rationale: Greenish-brown amniotic fluid is a sign of meconium in utero, which may indicate that the fetus is compromised. There is not enough information to determine than infection is present. If the fetal heart rate becomes non-reassuring, a cesarean birth will help ensure a viable newborn. Meconium-stained amniotic fluid is not an indication of imminent birth during the latent phase of labor.
A client at 37 weeks' gestation is admitted to the birthing unit from the emergency department. She arrived in an ambulance after a motor vehicle accident. Her blood pressure is 90/60 mm Hg, pulse is 108 beats/min, and respiratory rate is 24 breaths/min. She is reporting sharp abdominal pain. What is the priority nursing intervention at this time?
Applying an electronic fetal monitor Rationale: The client's clinical manifestations suggest abruptio placentae, and her vital signs indicate that shock may be occurring; determining fetal viability so that appropriate treatment may be instituted immediately is the priority. Preparing for a cesarean birth is premature until fetal viability has been determined. Obtaining a blood sample before assessing the status of the fetus is unsafe. The amount of vaginal bleeding is not relevant because there may be hidden bleeding.
A nurse is caring for a pregnant client with type 1 diabetes having amniocentesis. She is in the 37th week of gestation and has been experiencing signs of preeclampsia. The purpose of the amniocentesis is to determine:
Fetal lung maturity. Rationale: An amniocentesis at this stage of gestation is performed to determine fetal lung maturity. Gestational age is determined with the less invasive procedure of ultrasonography. Amniocentesis is performed between the 16th and 20th weeks to detect genetic disorders. Glucose level of the amniotic fluid is not the purpose for examining amniotic fluid.
A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most likely predispose a client to postpartum hemorrhage?
Multifetal pregnancy Rationale: More than one fetus over distends the uterus, which may result in uterine atony. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage
