Newborn Saunders
Which of the following physical findings would lead the nurse to suspect that a client with severe pre-eclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.
2. Petechiae. 3. Jaundice.
A client with mild pre-eclampsia who has been advised to be on bedrest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bedrest will help you to conserve energy for your labor." 2. "Bedrest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."
3. Bedrest, especially side-lying, helps to improve perfusion to the placenta. The vital organs of pre- eclamptic clients are being poorly perfused as a result of the abnormally high blood pressure. When a woman lies on her side, blood return to the heart is improved and the cardiac output is also improved. With improved cardiac output, perfusion to the placenta and other organs is improved.
A nurse is conducting a review course on Tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. A. nifedipine B. magnesium sulfate C. dinoprostone D. misoprostol E. indomethacin
A. nifedipine E. indomethacin B. magnesium sulfate Rationale: Medications most commonly used for tocolysis include magnesium sulfate (which reduces the muscle's ability to contract), indomethacin (a prostaglandin synthetase inhibitor), and nifedipine (a calcium channel blocker). These drugs are used "off label": this means they are effective for this purpose but have not been officially tested and developed for this purpose by the FDA. Dinoprostone and misoprostol are used to ripen the cervix.
A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation Recent onset of bright red vaginal bleeding, more than with previous episode No uterine contractions at present Fetal heart rate within normal range Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect? A. Placental abruption B. Placenta previa C. Ruptured ectopic pregnancy D. Polyhydramnios
B. Placenta previa Rationale: The assessment findings suggest placenta previa, a bleeding condition that occurs during the last two trimesters of pregnancy. It is characterized by slight birght red vaginal bleeding initially that stops spontaneously and then recurs later in amounts greater than the initial episode; absence of pain/contractions; soft, relaxed uterine tone; and a fetal heart rate within normal parameters. Placental abruption is characterized by a sudden onset with concealed or visible dark vaginal bleeding, utuerie tenderness and pain, with a firm or rigid uterus and fetal distress. The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. If ectopic rupture or hemorrhage occurs before treatment begins, symptoms may worsen and include severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity; feelings of faintness; referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation; hypotension; marked abdominal tenderness with distention; and hypovolemic shock. Polyhydramnios is initially suspected when uterine enlargement, maternal abdominal girth, and fundal height are larger than expected for the fetus's gestational age. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Shortness of breath and uterine contractions from overstretching may occur. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present.
A nurse is monitoring a client's hCG levels because she has had a previous ectopic pregnancy and one spontaneous abortion. Which finding would the nurse interpret as indicating that the pregnancy is progressing appropriately?A. doubling of the level every 2 to 3 days B. plateauing of the level at 7 days C. gradually increasing levels every month D. abruptly declining levels after 60 days
A. doubling of the level every 2 to 3 days
A woman is to receive methotrexate IM for an ectopic pregnancy. The nurse should teach the woman about which of the following common side effects of the therapy? Select all that apply. 1. Nausea and vomiting. 2. Abdominal pain. 3. Fatigue. 4. Light-headedness. 5. Breast tenderness.
1, 2, 3, and 4 are correct. Nausea and vomiting are common side effects. Abdominal pain is a common side effect. The pain associated with the medication needs to be carefully monitored to differentiate it from the pain caused by the ectopic pregnancy itself. Fatigue is a common side effect. Light-headedness is a common side effect.
Which of the following long-term goals is appropriate for a client, 10 weeks' gestation, who is diagnosed with gestational trophoblastic disease (hydatidiform mole)? 1. Client will be cancer-free 1 year from diagnosis. 2. Client will deliver her baby at full term without complications. 3. Client will be pain-free 3 months after diagnosis. 4. Client will have normal hemoglobin and hematocrit at delivery.
1. Client will be cancer-free 1 year from diagnosis. Risk for cancer. which will probably involve close clinical surveillance for approximately 1 year, and reinforce its importance in monitoring the client's condition. Tell the client that serial serum beta-hCG levels are used to detect residual trophoblastic tissue. Inform the client about the possible use of chemotherapy, such as methotrexate,
Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? Select all that apply. 1. 31 weeks' gestation with prolapsed mitral valve (PMV). 2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post-in vitro fertilization (IVF). 4. 34 weeks' gestation with gestational diabetes (GDM). 5. 35 weeks' gestation with deep vein thrombosis (DVT).
2. Clients with UTIs are at high risk for PPROM. 3. Clients carrying twins, whether spontaneous or post-IVF, are at high risk for PPROM.
Which of the following laboratory values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.
3. Platelets 75,000.
During a prenatal interview, a client tells the nurse, "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? 1. "Does your mother have a family history of cancer?" 2. "Did your mother tell you what she was toxic from?" 3. "Does your mother have diabetes now?" 4. "Did your mother say whether she had a seizure or not?"
4. "Did your mother say whether she had a seizure or not?" The hypertensive illnesses of pregnancy used to be called toxemia of pregnancy as well as pregnancy- induced hypertension. The term toxemia is still heard in the community because the mothers and grandmothers of clients were told that they had toxemia of pregnancy. Because daughters of clients who have had pre-eclampsia are at high risk for hypertensive illness, it is important to find out whether or not the client's mother had developed eclampsia.
A nurse is caring for a 25-year-old client who has just had a spontaneous first trimester abortion. Which of the following comments by the nurse is appropriate? 1. "You can try again very soon." 2. "It is probably better this way." 3. "At least you weren't very far along." 4. "I'm here to talk if you would like."
4. "I'm here to talk if you would like." The nurse should offer assistance to the client without making any assumptions about the client's feelings toward the pregnancy loss. Speaking platitudes is completely inappropriate.
A 26-week-gestation woman is diagnosed with severe pre-eclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.
4. Epigastric pain is associated with the liver involvement of HELLP syndrome. The acronym, HELLP, stands for the following signs/symptoms: hemolysis, elevated liver enzymes, and low platelets. When the liver is deprived of sufficient blood supply, as can occur with severe pre-eclampsia, the organ becomes ischemic and liver enzymes become elevated. In addition, the client experiences pain at the site of the liver as a result of the hypoxia in the liver.
A client has severe pre-eclampsia. The nurse would expect the primary healthcare practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.
4. Intrauterine growth restriction. Perfusion to the placenta drops when clients are pre-eclamptic because the client's hypertension impairs adequate blood flow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus's growth is affected.
A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor at home. The nurse determines that the teaching was successful based on which statements by the woman? Select all that apply. A. "I should check my blood pressure twice a day." B. "I will weigh myself once a week." C. "I should complete a fetal kick count each day." D. "I will check my urine for protein four times a day." E. "I'll call my health care provider if I have burning when I urinate."
A. "I should check my blood pressure twice a day." C. "I should complete a fetal kick count each day." E. "I'll call my health care provider if I have burning when I urinate." Rationale: The client should take her blood pressure twice daily, check and record weight daily, perform urine dipstick checks for protein twice daily, record the number of fetal kicks daily, and notify her health care provider if she experiences burning on urination.
A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion? A. Ultrasound B. Amniocentesis C. Human chorionic gonadotropin (hCG) level D. Triple marker screening
A. Ultrasound An ultrasound is necessary to confirm the absence of fetal cardiac activity
A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A. "My mother lives next door and can drive me here if necessary." B. "I have a toddler and preschooler at home who need my attention." C. "I know to call my health care provider right away if I start to bleed again." D. "I realize the importance of following the instructions for my care."
B. "I have a toddler and preschooler at home who need my attention." Rationale: Having a toddler and preschooler at home needing attention suggest that the woman would have difficulty maintaining bed rest at home. Therefore, expectant management at home may not be appropriate. Expectant management is appropriate if the mother and fetus are both stable, there is no active bleeding, the client has readily available access to reliable transportation, and can comprehend instructions.
A pregnant client with preeclampsia is being treated with intravenous magnesium sulfate. The nurse assesses the client's deep tendon reflexes and grades them as 4+. The nurse notifies the health care provider about this finding, describing them using which term to ensure accurate communication? A. Absent B. Average C. Brisk D. Clonus
D. Clonus A 4+ grade indicates clonus which is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms central nervous system involvement.
A woman is recovering at the gynecologist's office following a late first-trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following? 1. Maternal varicella titer. 2. Past obstetric history. 3. Maternal blood type. 4. Cervical patency.
It is essential that the woman's blood type be assessed. If the woman is found to be Rh-, even though the fetal blood type is unknown, the woman must receive a dose of RhoGAM within 72 hours of the abortion. If the fetus were Rh+ and the woman were not to receive RhoGAM, the woman's immune system might be stimulated to produce antibodies against Rh+ blood. Any future Rh+ fetus would be in danger of developing erythroblastosis fetalis. It is also important for the nurse to check the woman's rubella titer. If the woman is nonimmune to rubella, she should receive the MMR vaccine prior to discharge.
The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? 1. Take the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Assess for complaint of dizziness or weakness.
It is most important for the nurse to assess for complaints of dizziness or weakness. In this situation, the most important action for the nurse to perform is to assess for complaints of dizziness or weakness. These symptoms are seen when clients develop hypovolemia from internal bleeding. Internal bleeding will be present if the client's fallopian tube has ruptured.
A woman with a diagnosis of ectopic pregnancy is to receive medical intervention rather than a surgical interruption. Which of the following intramuscular medications would the nurse expect to administer? 1. Decadron (dexamethasone). 2. Amethopterin (methotrexate). 3. Pergonal (menotropin). 4. Prometrium (progesterone).
Methotrexate is the likely medication. Methotrexate is an antineoplastic agent. Even if the test taker were unfamiliar with its use in ectopic pregnancy but was aware of the action of methotrexate, he or she could deduce its efficacy here. Methotrexate is a folic acid antagonist that interferes with DNA synthesis and cell multiplication. The conceptus is a ball of rapidly multiplying cells. Methotrexate interferes with that multiplication, killing the conceptus and, therefore, precluding the need for the client to undergo surgery.
A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result? A. 3.3 mEq/L B. 6.1 mEq/L C. 8.4 mEq/L D. 10.8 mEq/L
Rationale: Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? A. at 32 weeks' gestation and immediately before discharge B. 24 hours before birth and 24 hours after birth C. in the first trimester and within 2 hours of birth D. at 28 weeks' gestation and again within 72 hours after birth
Rationale: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.
Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatidiform mole)? 1. Protracted pain. 2. Variable fetal heart decelerations. 3. Dark brown vaginal bleeding. 4. Suicidal ideations.
The condition is usually diagnosed after a client complains of brown vaginal discharge early in the "pregnancy." The most important thing to remember when answering questions about hydatidiform mole is the fact that, even though a positive pregnancy test has been reported, there is no "pregnancy." The normal conceptus develops into two portions—a blastocyst, which includes the fetus and amnion, and a trophoblast, which includes the fetal portion of the placenta and the chorion. In gestational trophoblastic disease (hydatidiform mole), only the trophoblastic layer develops; no fetus develops. With the proliferation of the chorionic layer, the client is at high risk for gynecological cancer.
A client, 32 weeks' gestation with placenta previa, is on total bedrest. The physician expects her to be hospitalized on bedrest until her cesarean section, which is scheduled for 38 weeks' gestation. To prevent complications while in the hospital, the nurse should do which of the following? Select all that apply. 1. Perform passive range-of-motion exercises. 2. Restrict the fluid intake of the client. 3. Decorate the room with pictures of family. 4. Encourage the client to eat a high-fiber diet. 5. Teach the client deep-breathing exercises.
1. Perform passive range-of-motion exercises. 3. Decorate the room with pictures of family. 4. Encourage the client to eat a high-fiber diet. 5. Teach the client deep-breathing exercises. Although bedrest is often used as therapy for antenatal clients, it does not come without its complications—constipation, depression, respiratory compromise, and muscle atrophy, to name but a few. The nurse must provide preventive care to maintain the health and well-being of the client as much as possible.
A 29-week-gestation woman diagnosed with severe pre-eclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus.
2. Papilledema. Increased intracranial pressure (ICP) is present in a client with severe pre-eclampsia because she is third spacing large quantities of fluid. As a result of the elevated ICP, the optic disk swells and papilledema is seen when the disk is viewed through an ophthalmoscope due to ICP from cranial edema
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A. hemorrhage B. jaundice C. edema D. infection
A. hemorrhage Rationale: With a ruptured ectopic pregnancy, the woman is at high risk for hemorrhage. Jaundice, edema, and infection are not associated with a ruptured ectopic pregnancy.
A woman, G4 P0210 and 12 weeks' gestation, has been admitted to the labor and delivery suite for a cerclage procedure. Which of the following long-term outcomes is appropriate for this client? 1. The client will gain less than 25 pounds during the pregnancy. 2. The client will deliver after 38 weeks' gestation. 3. The client will have a normal blood glucose throughout the pregnancy. 4. The client will deliver a baby who is appropriate for gestational age.
2. The client will deliver after 38 weeks' gestation. The gravidity and parity information provides an important clue to the question. The client has had four pregnancies—with two preterm births and one abortion, but she has no living children. The goal for the therapy, therefore, is that the pregnancy will go to term.
Which of the following findings would the nurse expect to see when assessing a first-trimester gravida suspected of having gestational trophoblastic disease (hydatidiform mole) that the nurse would not expect to see when assessing a first-trimester gravida with a normal pregnancy? Select all that apply. 1. Hematocrit 39%. 2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure. 4. White blood cell count 8,000/mm3.5. Hypertrophied breast tissue.
2. Women with hydatidiform mole often expel grape-like clusters from the vagina. 3. Although signs and symptoms of pre- eclampsia usually appear only after a pregnancy has reached 20 weeks or later, pre-eclampsia is seen in the first trimester of pregnancy in women with hydatidiform mole.
A client is admitted to the hospital with severe pre-eclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor.
3. Dorsiflex the woman's foot. When clients have severe pre-eclampsia, they are often hyperreflexic and develop clonus. To assess for clonus, the nurse should dorsiflex the foot and then let the foot go. The nurse should observe for and count any pulsations of the foot. The number of pulsations is documented. The higher the number of pulsations there are, the more irritable the woman's central nervous system is.
A gravid client, G6 P5005, 24 weeks' gestation, has been admitted to the hospital for placenta previa. Which of the following is an appropriate long-term goal for this client? 1. The client will state an understanding of need for complete bedrest. 2. The client will have a reactive nonstress test on day 2 of hospitalization. 3. The client will be symptom-free until at least 37 weeks' gestation. 4. The client will have normal vital signs on admission.
3. The client will be symptom-free until at least 37 weeks' gestation. 1. Women with placenta previa are often on bedrest. This is, however, a short-term goal. 2. 2. Another short-term goal is that the baby would have a reactive NST on day 2 of hospitalization.
Which of the following statements is appropriate for the nurse to say to a patient with a complete placenta previa? 1. "During the first phase of labor you will do slow chest breathing." 2. "You should ambulate in the halls at least two times each day." 3. "The doctor will deliver you once you reach 25 weeks' gestation." 4. "It is important that you inform me if you become constipated."
4. Straining at stool can result in enough pressure to result in placental bleeding.
1. After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful? A. "I will be sure to avoid getting pregnant for at least 1 year." B. "My intake of iron will have to be closely monitored for 6 months." C. "My blood pressure will continue to be increased for about 6 more months." D. "I won't use my birth control pills for at least a year or two."
A. "I will be sure to avoid getting pregnant for at least 1 year." Rationale: After evacuation of trophoblastic tissue (hydatiform mole), long-term follow-up is necessary to make sure any remaining trophoblastic tissue does not become malignant. Serial hCG levels are monitored closely for 1 year, and the client is urged to avoid pregnancy for 1 year because it can interfere with the monitoring of hCG levels. Iron intake and blood pressure are not important aspects of follow up after evacuation of a hydatiform mole. Use of a reliable contraceptive is strongly recommended so that pregnancy is avoided.
A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available? A. calcium gluconate B. potassium chloride C. ferrous sulfate D. calcium carbonate
A. calcium gluconate Rationale: The woman is at risk for magnesium toxicity. The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with pre-eclampsia. In addition to obtaining baseline vital signs and placing the client on bedrest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.
1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. Pre-eclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the urinalysis. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the pre- eclampsia. For example, if the reflexes are +2, the client would be much less likely to become eclamptic, that is, have a seizure, than a client who has +4 reflexes with clonus.
A nurse is reviewing an article about preterm prelabor rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply. A. high body mass index B. urinary tract infection C. low socioeconomic status D. single gestations E. smoking
B. urinary tract infection C. low socioeconomic status E. smoking Rationale: High-risk factors associated with prelabor rupture of membranes (PROM) include low socioeconomic status, multiple gestation, low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis
A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make? A. "Make sure that anything around your waist is quite snug." B. "Try to eat three large meals a day with less snacking." C. "Drink fluids in between meals rather than with meals." D. "Lie down for about an hour after you eat."
C. "Drink fluids in between meals rather than with meals." Rationale: Suggestions to minimize nausea and vomiting include avoiding tight waistbands to minimize pressure on the abdomen, eating small frequent meals throughout the day, separating fluids from solids by consuming fluids in between meals; and avoiding lying down or reclining for at least 2 hours after eating.
17. A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching? A. "I need to keep a close eye on how active my baby is each day." B. "I need to call my doctor if my temperature increases." C. "It's okay for my husband and me to have sexual intercourse." D. "I can shower, but I shouldn't take a tub bath."
C. "It's okay for my husband and me to have sexual intercourse." Rationale: The woman with preterm prelabor rupture of membranes should monitor her baby's activity by performing fetal kick counts daily, check her temperature and report any increases to the health care provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and avoid sitting in a tub bath.
A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of placental abruption (abruptio placentae) during birth. Which finding would help to support the nurse's suspicion? A. severe uterine pain B. board-like abdomen C. appearance of petechiae D. inversion of the uterus
C. appearance of petechiae Rationale: A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with DIC and placental abruption.
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care? A. clear liquid diet B. total parenteral nutrition C. nothing by mouth D. administration of labetalol
C. nothing by mouth Rationale: Typically, on admission, the woman with hyperemesis has oral food and fluids withheld to rest the gut and receives parenteral fluids to rehydrate and reduce the symptoms. Once the condition stabilizes, oral intake is gradually increased. Total parenteral nutrition may be used if the client's condition does not improve with several days of bed rest, gut rest, IV fluids, and antiemetics. Labetalol is an antihypertensive agent that may be used to treat gestational hypertension, not hyperemesis.
A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A. use of oral contraceptives for 5 years B. ovarian cyst 2 years ago C. recurrent pelvic infections D. heavy, irregular menses
C. recurrent pelvic infections Rationale: In the general population, most cases of ectopic pregnancy are the result of tubal scarring secondary to pelvic inflammatory disease. Oral contraceptives, ovarian cysts, and heavy, irregular menses are not considered risk factors for ectopic pregnancy.
A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia? A. urine protein 300 mg/24 hours B. blood pressure 150/96 mm Hg C. mild facial edema D. hyperreflexia
D. hyperreflexia Rationale: Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours, and hyperreflexia. Mild facial edema is associated with mild preeclampsia.
1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. supine B. side-lying C. sitting D. knee-chest
D. knee-chest Rationale: Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee-chest position. Supine, side-lying, or sitting would not provide relief of cord compression.
A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis?1. Dark brown rectal bleeding. 2. Severe nausea and vomiting. 3. Sharp unilateral pain. 4. Marked hyperthermia.
Sharp unilateral pain is a common symptom of a ruptured ectopic. The most common location for an ectopic pregnancy to implant is in a fallopian tube. Because the tubes are nonelastic, when the pregnancy becomes too big, the tube ruptures. Unilateral pain can develop because only one tube is being affected by the condition, but some women complain of generalized abdominal pain.
A client, G2 P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?" 2. "When was the first day of your last menstrual period?" 3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"
The date of the last menstrual period will assist the nurse in determining how many weeks pregnant the client is. The date of the last menstrual period is important for the nurse to know. Ectopic pregnancies are usually diagnosed between the 8th and the 9th week of gestation because, at that gestational age, the conceptus has reached a size that is too large for the fallopian tube to hold.
