Maternity Chapter 10+: Complications of Pregnancy

32. As the triage nurse in the emergency room, you are reviewing results for the high- risk obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that: a. immediate birth is required. b. the client should be transferred to the critical care unit for closer observation. c. RhoGAM should be administered. d. a tetanus shot should be administered.

ANS: A A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma. The client should be transferred to the obstetric area for birth, not the critical care unit setting. PTS: 1 DIF: Cognitive Level: Analysis REF: 516

8. Spontaneous termination of a pregnancy is considered to be an abortion if: a. the pregnancy is less than 20 weeks. b. the fetus weighs less than 1000 g. c. the products of conception are passed intact. d. there is no evidence of intrauterine infection.

ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some fetuses of an older age may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection. PTS: 1 DIF: Cognitive Level: Understanding REF: 505

23. A laboratory finding indicative of DIC is: a. decreased fibrinogen. b. increased platelets. c. increased hematocrit. d. decreased thromboplastin time.

ANS: A DIC develops when the blood-clotting factor thromboplastin is released into the maternal bloodstream as a result of placental bleeding. Thromboplastin activates widespread clotting, which uses the available fibrinogen, resulting in a decreased fibrinogen level. The platelet count will decrease. The hematocrit may decrease if bleeding is pronounced. The thromboplastin time is prolonged. PTS: 1 DIF: Cognitive Level: Analysis REF: 507

28. A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days' duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder. The client's last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect? a. Ectopic pregnancy b. Appendicitis c. Food poisoning d. Gastroenteritis

ANS: A Even though the client's menstrual cycle has variability, all women are considered to be pregnant until proven otherwise. The client's presenting symptoms are typical for ectopic pregnancy, so the client should be monitored for the possible complication of rupture and shock. PTS: 1 DIF: Cognitive Level: Application REF: 507, 508

31. A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome? a. Platelet count of 50,000/mL b. Liver enzyme levels within normal range c. Negative for edema d. No evidence of nausea or vomiting

ANS: A HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet count. A platelet count of 50,000/mL indicates thrombocytopenia. PTS: 1 DIF: Cognitive Level: Analysis REF: 529

62. The emergency room charge nurse calls the labor and birth charge nurse and reports the ambulance is en route with a seizing pregnant patient at 36 weeks' gestation. What medication will the charge nurse most likely direct the staff nurse to prepare to administer immediately on the patient's arrival to the labor and birth unit? a. Magnesium sulfate (magnesium) b. Hydralazine (Apresoline) c. Carbamazepine (Tegretol) d. Terbutaline (Brethine)

ANS: A Magnesium sulfate is the drug most often used for preeclamptic and eclamptic patients. It is a CNS depressant. Apresoline is administered for hypertension and is often given to pregnant clients with severe preeclampsia. Tegretol is administered for seizure activity in nonpregnant patients. Brethine is a smooth muscle relaxant administered for preterm labor. PTS: 1 DIF: Cognitive Level: Application REF: 523

46. What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding? a. Treated 1 year ago for pelvic inflammatory disease (PID) b. Oral contraception for last 3 years c. Urinary frequency for 1 week d. Irregular cycles for 1 year prior to conception

ANS: A PID causes fallopian tube damage. Blockage of the tube prevents movement of the fertilized ovum, resulting in implantation in the tube. Oral contraception for the last 3 years, urinary frequency for 1 week, and irregular cycles for 1 year prior to conception have no effect on the development of ectopic pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 508

4. Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome? a. Abdominal palpation b. Venous sample of blood c. Checking deep tendon reflexes d. Auscultation of the heart and lungs

ANS: A Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia. PTS: 1 DIF: Cognitive Level: Application REF: 529

54. For the client who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to: a. 6:30 AM on January 13. b. 6:30 PM on January 13. c. 6:30 PM on January 14. d. 6:30 AM on January 15.

ANS: A Rho(D) immune globulin (RhoGAM) must be administered within 72 hours after the birth of an Rh-positive infant. 6:30 PM on January 13, 6:30 PM on January 14, and 6:30 AM on January 15 do not fall within the established time frame. PTS: 1 DIF: Cognitive Level: Application REF: 532

26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following? a. Hemorrhage is the major concern. b. She will be unable to conceive in the future. c. Bed rest and analgesics are the recommended treatment. d. A D&C will be performed to remove the products of conception.

ANS: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, her fertility will decrease but she will not be infertile. The recommended treatment is to remove the pregnancy before hemorrhaging. A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes. PTS: 1 DIF: Cognitive Level: Understanding REF: 507, 508

60. The clinic nurse is reviewing home care dietary instructions for the patient diagnosed with mild preeclampsia at 34 weeks' gestation. The nurse determines that the client requires additional information when she makes which statement? a. "I will limit my salt intake to 2 grams per day." b. "I will drink no less than 2500 mL of fluid per day." c. "I will make sure I eat 4 sources of protein per day." d. "My overall intake of calories per day should be around 2500."

ANS: A The diet should have ample protein, no less than 6 ounces/day, and approximately 2500 calories during the second half of pregnancy. A regular diet without salt or fluid restriction is usually prescribed. Adequate amounts of protein are essential, especially because there is pathologic protein loss with preeclampsia. PTS: 1 DIF: Cognitive Level: Application REF: 530

56. A patient reports to the emergency room nurse that she is 10 weeks pregnant, with unilateral pelvic pain, shoulder pain, and faintness. Her color is pale, she is diaphoretic, and her heart rate is 140 bpm. What is the nurse's priority action? a. Initiate an ordered IV of lactated Ringer's at 200 mL/hr. b. Take the patient for her ordered pelvic ultrasound. c. Ask the patient if she has had any recent vaginal bleeding. d. Ask the patient if she has ever been told she has had salpingitis.

ANS: A This patient is presenting with classic signs of an ectopic pregnancy and hypovolemic shock. This is an obstetric emergency. Symptoms include sudden, severe pain in one of the lower quadrants of the abdomen as the tube tears open and the embryo is expelled into the pelvic cavity, often with profuse abdominal hemorrhage. Radiating pain under the scapula may indicate bleeding into the abdomen caused by phrenic nerve irritation. Hypovolemic shock (acute peripheral circulatory failure from loss of circulating blood) is a major concern because systemic signs of shock may be rapid and extensive without external bleeding. The nurse must first start the IV to initiate rapid fluid replacement. Further assessment will result in a delay of care. PTS: 1 DIF: Cognitive Level: Synthesis REF: 509

37. Which finding should be the nurse's priority in a client suspected as having gestational trophoblastic disease? a. Uterine contractions b. Nausea and vomiting c. Blood pressure of 130/80 mm Hg d. Increase discharge of vaginal mucus

ANS: A Uterine contractions can cause trophoblastic tissue to be pulled into large venous sinusoids in the uterus, resulting in embolization of the tissue and respiratory distress. Nausea and vomiting and blood pressure of 130/80 mm Hg represent no immediate danger to the client and can be addressed later. Increased discharge of vaginal mucus is a normal finding in pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 510

21. Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa? a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding or leakage of amniotic fluid d. Determining frequency, duration, and intensity of contractions

ANS: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this client. Monitoring for bleeding and rupture of membranes is not contraindicated with this client. Monitoring contractions is not contraindicated with this client. PTS: 1 DIF: Cognitive Level: Analysis REF: 512

67. The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms? (Select all that apply.) a. Pelvic pain b. Missed period c. Abdominal pain d. Unanticipated heavy bleeding e. Vaginal spotting or light bleeding

ANS: A, B, C, E A missed period or spotting can easily be mistaken by the client as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about 50% of women, shoulder and neck pain occurs because of irritation of the diaphragm from the hemorrhage. PTS: 1 DIF: Cognitive Level: Application REF: 509

65. Which interventions may be indicated for the clinical management of hyperemesis gravidarum (HEG)? (Select all that apply.) a. Pyridoxine b. Total parenteral nutrition (TPN) for severe cases c. Promethazine (Phenergan) d. Levaquin (Levofloxacin) e. Omeprazole (Prilosec) f. Diphenhydramine (Benadryl)

ANS: A, B, C, E, F Pyridoxine (vitamin B6) may be indicated for the treatment of HEG. TPN is indicated for severe conditions. Phenergan, an antiemetic, and Prilosec, a gastric acid inhibitor, are also used for treatment of this condition. Benadryl is also used for treatment. An antibiotic such as Levaquin is not indicated for the treatment of this disease. PTS: 1 DIF: Cognitive Level: Analysis REF: 506

66. The physician suspects that the client may have gestational trophoblastic disease. Which clinical manifestations support this diagnosis? (Select all that apply.) a. Increased levels of beta-hCG in the serum b. Fundal height correlating with reported gestational age c. Vaginal bleeding d. Vomiting e. Maternal hypotension

ANS: A, C, D In gestational trophoblastic disease (molar pregnancy), the following clinical manifestations would appear: increased serum beta-hCG levels, increased size of the uterus related to gestational age, nausea and vomiting, and evidence of vaginal bleeding. Development of preeclampsia earlier in the pregnancy would be noted, resulting in hypertension, not hypotension. PTS: 1 DIF: Cognitive Level: Analysis REF: 518

18. Which orders should the nurse expect for a client admitted with a threatened abortion? a. NPO b. Pad count c. Ritodrine IV d. Meperidine (Demerol), 50 mg now

ANS: B A client admitted with a threatened abortion should be instructed to count the number of perineal pads used and to note the quantity and color of blood on the pads. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the client NPO. At times, dehydration may produce contractions, so hydration is important. Demerol will not decrease the contractions but may mask the severity of the contractions. PTS: 1 DIF: Cognitive Level: Application REF: 505

45. Which information should the labor nurse recognize as being pertinent to a possible diagnosis of abruptio placentae? a. Low back pain b. Firm, tender uterus c. Regular uterine contractions d. Scant vaginal mucus drainage

ANS: B A firm, tender uterus is a classic sign of abruptio placentae; low back pain, regular uterine contractions, and scant vaginal mucus drainage are normal findings in a laboring client. PTS: 1 DIF: Cognitive Level: Analysis REF: 515

44. Which explanation of a marginal placenta previa would the nurse provide to her client? a. The placenta is in the lower uterus, completely covering the internal cervical os. b. The placenta is in the lower uterus, more than 3 cm from the internal cervical os. c. The placenta is in the lower uterus, less than 3 cm from the internal cervical os. d. The placenta is in the lower uterus, at the edge and partially covering the cervical os.

ANS: B A marginal placenta, also called a low-lying placenta, is more than 3 cm from the internal cervical os. The placenta in the lower uterus, completely covering the internal cervical os, describes a total placenta previa. The placenta in the lower uterus, less than 3 cm from the internal cervical os, and the placenta in the lower uterus, at the edge and partially covering the cervical os, are both descriptions of a partial placenta previa. PTS: 1 DIF: Cognitive Level: Application REF: 513

9. An abortion when the fetus dies but is retained in the uterus is called: a. inevitable. b. missed. c. incomplete. d. threatened.

ANS: B A missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all the products of conception were expelled. With a threatened abortion, the client has cramping and bleeding but not cervical dilation. PTS: 1 DIF: Cognitive Level: Understanding REF: 506

35. Which assessment finding indicates an adverse response to magnesium sulfate? a. Urine output of 30 mL/hr b. Respiratory rate of 11 breaths/min c. Hypoactive patellar reflex d. Blood pressure reading of 110/80 mm Hg

ANS: B A respiratory rate less than 12 breaths/min indicates magnesium toxicity and requires immediate intervention. A urine output of 30 mL/hr is normal urinary output; a hypoactive patellar reflex and blood pressure reading of 110/80 mm Hg are normal findings in the client receiving magnesium sulfate. PTS: 1 DIF: Cognitive Level: Analysis REF: 525

52. Which intervention would be the most effective if your client who is on magnesium sulfate has a respiratory rate of 10 breaths/min? a. Give oxygen by mask at 8-10 L/min. b. Administer calcium gluconate via IV pyelogram (IVP). c. Arouse client with tactile stimulation. d. Continually assess pulse oximeter levels.

ANS: B A respiratory rate of less than 12 breaths/min in a client receiving magnesium sulfate is a sign of magnesium toxicity, which must be immediately reversed. Calcium gluconate opposes the effects of magnesium at the neuromuscular junction and is an antidote for magnesium toxicity. Oxygen by mask at 8 to 10 L/min, arousing a client with tactile stimulation, and continually assessing pulse oximeter levels will not be effective until the magnesium toxicity has been reversed. PTS: 1 DIF: Cognitive Level: Application REF: 525

12. The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to: a. monitor uterine contractions. b. assess fetal heart rate and maternal vital signs. c. place clean disposable pads to collect any drainage. d. perform a venipuncture for hemoglobin and hematocrit levels.

ANS: B Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and fetal well-being. The blood levels can be obtained later. PTS: 1 DIF: Cognitive Level: Application REF: 516

25. A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? a. Increase the client's IV fluids. b. Administer calcium gluconate. c. Vigorously stimulate the client. d. Instruct the client to take deep breaths.

ANS: B Calcium gluconate reverses the effects of magnesium sulfate. Increasing the client's IV fluids will not reverse the effects of the medication. Stimulation will not increase the respirations. Deep breaths will not be successful in reversing the effects of the magnesium sulfate. PTS: 1 DIF: Cognitive Level: Application REF: 525

11. Which would indicate concealed hemorrhage in abruptio placentae? a. Bradycardia b. Hard boardlike abdomen c. Decrease in fundal height d. Decrease in abdominal pain

ANS: B Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. The client will have shock symptoms that include tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase. PTS: 1 DIF: Cognitive Level: Analysis REF: 516

16. Rh incompatibility can occur if the client is Rh-negative and the: a. fetus is Rh-negative. b. fetus is Rh-positive. c. father is Rh-positive. d. father and fetus are both Rh-negative.

ANS: B For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood types are compatible and no problems should occur. The father's Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rh-negative, the blood type with the mother is compatible. The father's blood type does not enter into the problem. PTS: 1 DIF: Cognitive Level: Understanding REF: 530

6. A client is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. Which potential problem should be investigated? a. Placenta previa b. Hydatidiform mole c. Abruptio placentae d. Disseminated intravascular coagulation (DIC)

ANS: B Gestational trophoblastic disease (hydatidiform mole) is usually detected in the first trimester of pregnancy. The frequency of this condition is highest at both ends of a woman's reproductive life. Placenta previa usually occurs in the third trimester. Painless uterine bleeding is the classic symptom. Abruptio placentae usually occurs in the third trimester. Painful uterine bleeding is the classic symptom. DIC is a life-threatening complication of abruptio placentae, in which procoagulation and anticoagulation factors are simultaneously activated. PTS: 1 DIF: Cognitive Level: Analysis REF: 510

36. Which finding could cause the nurse to suspect gestational trophoblastic disease in a client at 8 weeks' gestation? a. Blood pressure of 128/70 mm Hg b. Fundal height of 12 cm c. Nausea and vomiting d. Weight gain of 3 pounds

ANS: B Gestational trophoblastic disease is characterized by proliferation and edema of the chorionic villi. The fluid-filled villi form grapelike clusters of tissue that can rapidly grow to fill the uterus to the size of a more advanced pregnancy. Blood pressure of 128/70 mm Hg, nausea and vomiting, and weight gain of 3 pounds are all normal findings in the first trimester. PTS: 1 DIF: Cognitive Level: Analysis REF: 510

2. Which is the only known cure for preeclampsia? a. Magnesium sulfate b. Delivery of the fetus c. Antihypertensive medications d. Administration of aspirin (ASA) every day of the pregnancy

ANS: B If the fetus is viable and near term, birth is the only known cure for preeclampsia. Magnesium sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (60 to 80 mg) have been administered to women at high risk for developing preeclampsia. PTS: 1 DIF: Cognitive Level: Understanding REF: 519

7. Which maternal condition always necessitates birth by cesarean section? a. Partial abruptio placentae b. Total placenta previa c. Ectopic pregnancy d. Eclampsia

ANS: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal birth occurred. If the client has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has died, a vaginal birth is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control. PTS: 1 DIF: Cognitive Level: Understanding REF: 512

19. Which data found on a client's health history would place her at risk for an ectopic pregnancy? a. Ovarian cyst 2 years ago b. Recurrent pelvic infections c. Use of oral contraceptives for 5 years d. Heavy menstrual flow of 4 days' duration

ANS: B Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic pregnancies. Heavy menstrual flow of 4 days' duration will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies. PTS: 1 DIF: Cognitive Level: Understanding REF: 508

50. Which assessment finding suggests that your laboring client's blood magnesium level is too high? a. Hyperactive reflexes b. Absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr

ANS: B Magnesium acts as a central nervous system depressant by blocking neuromuscular transmission. Assessment of the deep tendon reflexes is an indication of the level of CNS depression. Absent reflexes indicates magnesium toxicity; hyperactive reflexes, generalized seizure, and urine output of 60 mL/hr are not symptoms of magnesium toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 526

40. Which assessment by the nurse would differentiate a placenta previa from an abruptio placentae? a. Saturated perineal pad in 1 hour b. Pain level 0 on a scale of 0 to 10 c. Cervical dilation at 2 cm d. Fetal heart rate at 160 bpm

ANS: B The classic sign of placenta previa is the sudden onset of painless uterine bleeding, whereas abruptio placentae results in abdominal pain and uterine tenderness; heavy bleeding, cervical dilation, and fetal heart rate of 160 bpm could be associated with both conditions. PTS: 1 DIF: Cognitive Level: Analysis REF: 513

29. A client who was pregnant had a spontaneous abortion at approximately 4 weeks' gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of "crampy" abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100° F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis? a. Ectopic pregnancy b. Uterine infection c. Gestational trophoblastic disease d. Endometriosis

ANS: B The client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals. Because the pregnancy test is negative, an undiagnosed ectopic pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical diagnosis of endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated. PTS: 1 DIF: Cognitive Level: Analysis REF: 506

47. Which of these interventions should the nurse recognize as the priority for the client diagnosed with an intact tubal pregnancy? a. Assessment of pain level b. Administration of methotrexate c. Administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan

ANS: B The goal of medical management of an intact tube is to preserve the tube and improve the chance of future fertility. Methotrexate (a folic acid antagonist) is used to inhibit cell division and stop growth of the embryo. Assessment of pain level, administration of Rh immune globulin, and explaining common side effects of the treatment plan should be implemented in conjunction with or soon after treatment with methotrexate has begun. PTS: 1 DIF: Cognitive Level: Analysis REF: 509

59. A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted? a. Obtain the patient's weight. b. Take the patient's vital signs. c. Start an IV with lactated Ringer's at 75 mL/hr. d. Ask support persons to leave the birthing room.

ANS: B The hallmark signs of preeclampsia are hypertension and proteinuria. These parameters must be evaluated first. Obtaining the patient's weight may indicate excess fluid gain, but fluid retention does not occur in all cases of preeclampsia. An IV will be beneficial; however, assessment precedes implementation in this case to obtain baseline data. Promoting a nonstimulating environment can help decrease blood pressure; however, loss of support during this frightening time can increase anxiety in this initial assessment phase and actually increase the patient's blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 519

61. A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient's magnesium level is 7.6 mg/dL. What is the nurse's priority action? a. Stop the infusion of magnesium. b. Assess the patient's respiratory rate. c. Assess the patient's deep tendon reflexes. d. Notify the health care provider of the magnesium level.

ANS: B The therapeutic serum level for magnesium is 4 to 8 mg/dL although it is elevated in terms of normal lab values. Adverse reactions to magnesium sulfate usually occur if the serum level becomes too high. The most important is CNS depression, including depression of the respiratory center. Magnesium is excreted solely by the kidneys, and the reduced urine output that often occurs in preeclampsia allows magnesium to accumulate to toxic levels in the woman. Frequent assessment of serum magnesium levels, deep tendon reflexes, respiratory rate, and oxygen saturation can identify CNS depression before it progresses to respiratory depression or cardiac dysfunction. Monitoring urine output identifies oliguria that would allow magnesium to accumulate and reach excessive levels. Discontinue magnesium if the respiratory rate is below 12 breaths/min, a low pulse oximeter level (<95%) persists, or deep tendon reflexes are absent. Additional magnesium will make the condition worse. PTS: 1 DIF: Cognitive Level: Analysis REF: 524

68. The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (Select all that apply.) a. Cool, clammy skin b. Altered sensorium c. Pulse oximeter reading of 95% d. Respiratory rate of less than 12 breaths/min e. Absence of deep tendon reflexes

ANS: B, D, E Signs of magnesium toxicity include the following: · Respiratory rate of less than 12 breaths/min (hospitals may specify a rate < 14 breaths/min) · Maternal pulse oximeter reading lower than 95% · Absence of deep tendon reflexes · Sweating, flushing · Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented) · Hypotension · Serum magnesium value above the therapeutic range of 4 to 8 mg/dL Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 508

63. A preeclamptic patient is receiving an IV infusion of magnesium sulfate. On assessment, the nurse notes that the patient's urinary output has been 20 mL/hr for the past 2 hours and her deep tendon reflexes are absent. The health care provider prescribes calcium gluconate, 1 g of a 10% solution. The standard rate of infusion is 1 mL/min. How many minutes will it take for the nurse to administer the prescribed calcium? a. 1 b. 5 c. 10 d. 15

ANS: C A 10% solution contains 10 g in 100 mL. X minutes = 1 minute ´ 100 mL ´ 1 g = 10 minutes 1 mL 10 g PTS: 1 DIF: Cognitive Level: Analysis REF: 528

51. What should the nurse recognize as evidence that the client is recovering from preeclampsia? a. 1+ protein in urine b. 2+ pitting edema in lower extremities c. Urine output >100 mL/hr d. Deep tendon reflexes +2

ANS: C Rapid reduction of the edema associated with preeclampsia results in urinary output of 4 to 6 L/day as interstitial fluids shift back to the circulatory system. 1+ protein in urine and 2+ pitting edema in lower extremities are signs of continuing preeclampsia. Deep tendon reflexes are not a reliable sign, especially if the client has been treated with magnesium. PTS: 1 DIF: Cognitive Level: Analysis REF: 525

53. Fraternal twins are delivered by your Rh-negative client. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the: a. direct Coombs test of twin A. b. direct Coombs test of twin B. c. indirect Coombs test of the mother. d. transcutaneous bilirubin level for both twins.

ANS: C Administration of RhoGAM is based on the results of the indirect Coombs test on the client. A negative results confirms that the mother has not been sensitized by the positive Rh factor of twin A and that RhoGAM is indicated. A direct Coombs test is a diagnostic test used to determine maternal antibodies in fetal blood and to guide treatment of the newborn when Rh and ABO incompatibilities occur. Transcutaneous bilirubin is a noninvasive measure to determine the level of bilirubin in a newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 530

1. A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic. c. anticonvulsant. d. antihypertensive.

ANS: C Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate. PTS: 1 DIF: Cognitive Level: Understanding REF: 523

48. Which finding in the exam of a client with a diagnosis of threatened abortion would change the diagnosis to inevitable abortion? a. Presence of backache b. Rise in hCG level c. Clear fluid from vagina d. Pelvic pressure

ANS: C Clear fluid from the vagina indicates rupture of the membranes. Abortion is usually inevitable (cannot be stopped) when the membranes rupture, the presence of backache and pelvic pressure are common symptoms in threatened abortion, and a rise in the hCG level is consistent with a viable pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 506

39. Which finding in the assessment of a client following an abruption placenta could indicate a major complication? a. Urine output of 30 mL in 1 hour b. Blood pressure of 110/60 mm Hg c. Bleeding at IV insertion site d. Respiratory rate of 16 breaths/min

ANS: C DIC is a life-threatening defect in coagulation that may occur following abruptio placentae. DIC allows excess bleeding from any vulnerable area such as IV sites, incisions, gums, or nose. A urine output of 30 mL in 1 hour, blood pressure of 110/60 mm Hg, and respiratory rate of 16 breaths/min are normal findings in a postpartum client. PTS: 1 DIF: Cognitive Level: Analysis REF: 507

5. A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? a. +1 b. +2 c. +3 d. +4

ANS: C Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal cavity. PTS: 1 DIF: Cognitive Level: Application REF: 526

3. The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia? a. Edema b. Proteinuria c. Glucosuria d. Hypertension

ANS: C Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant client is rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first indication of preeclampsia is usually an increase in the maternal blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: 521

38. What is the priority nursing intervention for the client who has had an incomplete abortion? a. Methylergonovine (Methergine), 0.2 mg IM b. Preoperative teaching for surgery c. Insertion of IV line for fluid replacement d. Positioning of client in left side-lying position

ANS: C Initial treatment of an incomplete abortion should be focused on stabilizing the client's cardiovascular state. Methylergonovine would be administered after surgical treatment, preoperative teaching is not a priority until the client is stabilized, and the left side-lying position provides no benefit to the client in this situation. PTS: 1 DIF: Cognitive Level: Application REF: 506

24. Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication? a. Drowsiness b. Urinary output of 20 mL/hr c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/min

ANS: C Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hr is not adequate output. A respiratory rate of 10 to 12 breaths/min is too slow and could be indicative of magnesium toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 525

43. In addition to obtaining vital signs and FHT, what is a priority for the client with placenta previa? a. Determining cervical dilation b. Monitoring uterine contractions c. Estimating blood loss d. Starting a Pitocin drip

ANS: C Nursing assessments for the client with placenta previa focus on determining the amount of blood loss. The nurse does not perform vaginal exams on a client with placenta previa because of the risk of perforating the placenta, the client may or may not be experiencing contractions, and induction is not indicated for a client with placenta previa. PTS: 1 DIF: Cognitive Level: Application REF: 512

41. A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL. a. 1800 b. 450 c. 900 d. 90

ANS: C One g equals 1 mL of blood. PTS: 1 DIF: Cognitive Level: Application REF: 511

22. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is: a. vaginal bleeding. b. rupture of membranes. c. presence of abdominal pain. d. changes in maternal vital signs.

ANS: C Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding. Both abruptio placentae and placenta previa may have vaginal bleeding. Rupture of membranes may occur with both conditions. Maternal vital signs may change with both if bleeding is pronounced. PTS: 1 DIF: Cognitive Level: Understanding REF: 515

34. The most appropriate nursing action for the client complaining of continuous headache 24 hours postpartum after a normal vaginal birth is to: a. encourage bed rest. b. administer analgesic. c. assess blood pressure. d. assess for pitting edema.

ANS: C The first indication of preeclampsia is usually hypertension. Continuous headache indicates poor cerebral perfusion and may be a precursor of seizures; encouraging bed rest, administering an analgesic, and assessing for edema are not interventions to determine the source of the client's headache. PTS: 1 DIF: Cognitive Level: Application REF: 521

14. A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to: a. advise her to cut down on fast foods that are high in fat. b. caution her to avoid salty foods and to return in 2 weeks. c. assess weight gain, location of edema, and urine for protein. d. recommend she stay home from school for a few days to reduce stress.

ANS: C The nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she needs further assessment to determine if pregnancy-induced hypertension is the problem. PTS: 1 DIF: Cognitive Level: Application REF: 526

27. You are taking care of a client who had a therapeutic abortion following an episode of vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks postprocedure as a follow-up to medical care. Which result indicates that additional intervention is needed? a. Hemoglobin, 13.2 mg/dL b. White blood cell count, 10,000 mm3 c. Beta-hCG detected in serum d. Fasting blood glucose level, 80 mg/dL

ANS: C The presence of beta-hCG in serum 2 weeks after the procedure is clinically significant and indicates the possibility that there may have been a molar pregnancy (hydatidiform). Thus, further examination is required. None of the other lab results warrant intervention because they are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 509

57. The labor and birth nurse is reviewing the risk factors for placenta previa with a group of nursing students. The nurse determines that the students understood the discussion when they identify which patient being at the highest risk for developing a placenta previa? a. Female fetus, Mexican-American, primigravida b. Male fetus, Asian-American, previous preterm birth c. Male fetus, African-American, previous cesarean section d. Female fetus, European-American, previous spontaneous abortion

ANS: C The rate of placenta previa is increasing. It is more common in older women, multiparous women, women who have had cesarean births, and women who had suction curettage for an induced or spontaneous abortion. It is also more likely to recur if a woman has had a placenta previa. African or Asian ethnicity also increases the risk. Cigarette smoking and cocaine use are personal habits that add to a woman's risk for a previa. Previa is more likely if the fetus is male. The Mexican-American primipara has no risk factors for developing a placenta previa. The Asian-American multipara has two risk factors for developing a previa. The African-American multipara has three risk factors for developing a previa. The European-American multigravida has one risk factor for developing a placenta previa. PTS: 1 DIF: Cognitive Level: Synthesis REF: 513

20. Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? a. Blood pressure of 120/80 mm Hg b. Complaint of frequent mild nausea c. Fundal height measurement of 18 cm d. History of bright red spotting for 1 day weeks ago

ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. A client with a molar pregnancy may have early-onset, pregnancy-induced hypertension. Nausea increases in a molar pregnancy because of the increased production of human chorionic gonadotropin (hCG). The history of bleeding is normally described as being of a brownish color. PTS: 1 DIF: Cognitive Level: Analysis REF: 510

58. A patient presents to labor and birth with complaints of persistent acute back pain at 36 weeks' gestation. The nursing assessment reveals a taught abdomen, fundal height at 40 cm, and late decelerations, with an FHR range of 124 to 128 bpm. The nurse will implement the protocol for which obstetric condition? a. Placenta previa b. Hypovolemic shock c. Abruptio placentae or abruption d. DIC

ANS: C There are five classic signs and symptoms of abruptio placentae and include the following: bleeding, which may be evident vaginally or be concealed behind the placenta; uterine tenderness, which may be localized at the site of the abruption; uterine irritability, with frequent low-intensity contractions and poor relaxation between contractions; abdominal or low back pain that may be described as aching or dull; and high uterine resting tone identified with the use of an intrauterine pressure catheter. Additional signs include nonreassuring FHR patterns, signs of hypovolemic shock, and fetal death. With a placenta previa there is bright red and painless bleeding. Hypovolemic shock can result from an abruption; however, if the protocol for shock is initiated, some of the blood work that can confirm an abruption will be omitted (e.g., a Kleihauer-Betke test). DIC can result from an abruption. First, look for the cause. PTS: 1 DIF: Cognitive Level: Analysis REF: 515

10. A placenta previa when the placental edge just reaches the internal os is called: a. total. b. partial. c. low-lying. d. marginal.

ANS: D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. With a partial previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os. PTS: 1 DIF: Cognitive Level: Understanding REF: 513

42. Which assessment finding on the fetal monitor strip supports a diagnosis of abruptio placentae? a. FHR of 150 bpm b. Moderate variability of FHR c. Contractions every 3 minutes d. Uterine resting tone of 30 mm Hg

ANS: D Abruptio placentae results in uterine irritability and a high resting uterine tone. A normal resting tone is from 5 to 15 mm Hg; FHR of 150 bpm, moderate variability of FHR, and contractions every 3 minutes are normal labor findings. PTS: 1 DIF: Cognitive Level: Analysis REF: 515

17. In which situation would a dilation and curettage (D&C) be indicated? a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks

ANS: D D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation. If all the products of conception have been passed (complete abortion), a D&C is not done. If the pregnancy is still viable (threatened abortion), a D&C is not done. PTS: 1 DIF: Cognitive Level: Understanding REF: 506

55. The nurse is providing care to a patient who just learned her baby has died in utero at 26 weeks' gestation. What is the nurse's next action? a. Contact the patient's clergy member. b. Enroll the patient in a grief and loss class. c. Determine if the patient is a victim of violence. d. Ask the patient when she last felt the baby move.

ANS: D Determining fetal movement will give the nurse a basis for how long the fetus has been expired. This patient is at risk for developing DIC, and the longer the fetus has been expired, the greater the risk. All the interventions listed are worth considering for this patient; however, the nurse must meet the patient's immediate physical needs first. PTS: 1 DIF: Cognitive Level: Synthesis REF: 523

30. A client with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting? a. Pregnancy-induced hypertension (PIH) b. Gestational hypertension c. Preeclampsia superimposed on chronic hypertension d. Undiagnosed chronic hypertension

ANS: D Even though the client has no documented prenatal care or medical history, she does relate a family history that is positive for heart disease. Additionally, the client's blood pressure increased following birth and was treated in the hospital and resolved. Now the client appears at the 6-week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to suggest that the client was preeclamptic prior to the birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 515

49. Which assessment finding indicates the development of preeclampsia in the antepartum client? a. Slight edema of feet and ankles. b. Increased urine output c. Blood pressure of 128/80 mm Hg d. Weight gain of 3 pounds in 1 week

ANS: D Generalized edema often occurs with preeclampsia. Edema may first manifest as a rapid weight gain. Normal weight gain in the second and third trimesters is 1 pound per week; slight edema of feet and ankles, increased urine output, and blood pressure of 128/80 mm Hg are normal findings in pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 521, 522

15. A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion.

ANS: D Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety. PTS: 1 DIF: Cognitive Level: Analysis REF: 520

64. The nurse is providing care to a laboring woman who is Rh-negative. The patient has a standing prescription to receive RhoGAM, if indicated. When will the nurse plan on administering the RhoGAM, if indicated? a. Approximately 2 hours prior to birth b. At the birth of the placenta c. One hour after the birth of the infant d. Between 48 and 72 hours after birth of the infant

ANS: D If the mother is Rh-negative, umbilical cord blood is taken at birth to determine blood type, Rh factor, and antibody titer (direct Coombs test) of the newborn. Rh-negative unsensitized mothers who give birth to Rh-positive infants are given an intramuscular injection of Rho(D) immune globulin (RhoGAM) within 72 hours after birth. If RhoGAM is given to the mother in the first 72 hours after the birth of an Rh-positive infant, Rh antigens present in her blood are destroyed before she forms antibodies to the Rh factor. If the infant is Rh-negative, Rh antibodies are not formed and RhoGAM is not necessary. Patients of the Jehovah's Witness faith decline blood-based products, and RhoGAM is derived from blood. It is the responsibility of the nurse to make sure that patients of this faith understand the characteristics of RhoGAM and are fully informed of the consequences of declining the administration of RhoGAM. PTS: 1 DIF: Cognitive Level: Application REF: 530

13. A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following? a. She should be isolated from her family. b. This condition is caused by psychogenic factors. c. The treatment is similar to that for morning sickness. d. She should be assessed for signs of dehydration and starvation.

ANS: D The cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications. Emotional support is essential to the care of this client. She needs the opportunity to express how it feels to live with constant nausea. The cause is unknown. The first attempts to control the nausea are to treat it like morning sickness, but if treatment is not successful, further care is needed. PTS: 1 DIF: Cognitive Level: Application REF: 518

33. A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring? a. Placental previa b. Active labor has started c. Placental abruption d. Hidden placental abruption

ANS: D The client's signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 515