OB Wrap Up AQ

A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? Persistent headache with blurred vision Epigastric pain with nausea and vomiting Spots and flashes of light before the eyes Rolling of the eyes to one side with a fixed stare

Rolling of the eyes to one side with a fixed stare (Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure. Persistent headache with blurred vision, epigastric pain with nausea and vomiting, and spots and flashes of light before the eyes are all clinical manifestations of severe preeclampsia, not eclampsia.)

A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur? Sixth Twelfth Sixteenth Eighteenth

Sixth (In the sixth week the fallopian tube can no longer expand to accommodate the size of the growing embryo. A tubal pregnancy cannot advance to the twelfth, sixteenth, or eighteenth week, because the tube cannot expand to accommodate the growing fetus.)

A nurse on the high-risk unit assesses a client admitted with severe preeclampsia. The client has audible crackles in the lower left lobe, slight blurring of vision in the right eye, generalized facial edema, and epigastric discomfort. Which clinical manifestation indicates the potential for a seizure? Audible crackles Blurring of vision Epigastric discomfort Generalized facial edema

Epigastric discomfort (Epigastric discomfort suggests liver edema; it is an ominous symptom that indicates an impending seizure. Audible crackles indicate pulmonary edema, but although they are a sign of severe preeclampsia they are not as definitive as epigastric pain. Blurred vision is a sign of retinal edema; although it is a sign of severe preeclampsia it is not as definitive as epigastric pain. Although generalized facial edema is an indication of severe preeclampsia, it is not as definitive as epigastric pain.)

What is the nurse's most critical assessment for a client with preeclampsia during the immediate postpartum period? Vital signs Emotional status Signs of hemorrhage Signs of hypovolemic shock

Vital signs (Clients with preeclampsia are at risk for compromised cardiovascular and renal function and are still at risk for seizures in the immediate postpartum period; frequent assessment is vital in the first 48 hours. Although it is an integral part of care, evaluating the client's emotional status is not the priority. This client is at no higher risk for hemorrhage than any other postpartum client. Monitoring the client for hypovolemic shock is not the priority assessment at this time.)

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. During her intake assessment, she tells the nurse that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? Assessing maternal vital signs Planning for an emergency birth Administering oxygen by way of nasal cannula Preparing for fetal scalp blood sampling

Assessing maternal vital signs (A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Administration of oxygen should be done with high flow oxygen via nonrebreather if assessment of the external monitoring is not reassuring, but this is not demonstrated in this scenario. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.)

During the initial prenatal visit of a woman at 23 weeks' gestation, the nurse discovers that she has a history of pica. What is the most appropriate nursing action? Seeking a psychology referral Explaining the danger this poses to the fetus Obtaining a prescription for an iron supplement Determining whether the diet is nutritionally adequate

Determining whether the diet is nutritionally adequate (The primary concern for a pregnant women who practices pica is that her diet is nutritionally inadequate. Nutritional guidance may be necessary, depending on the findings of this assessment. Pica does not indicate a psychologic/emotional disturbance; frequently it is influenced by the client's culture. If a substance is not toxic to the mother, it is generally not fetotoxic. Iron is routinely prescribed during pregnancy; this does not specifically address the practice of pica.)

The nurse is caring for a client who has had a spontaneous abortion. The client asks why spontaneous abortions occur. The nurse responds that they are most commonly caused by what? Physical trauma Unresolved stress Congenital defects Embryonic defects

Embryonic defects (Approximately 75% of all spontaneous abortions take place between 8 and 12 weeks' gestation and reveal embryonic defects. Though possible, physical trauma rarely causes an abortion. Unresolved stress is rarely associated with spontaneous abortions. Congenital defects are asymptomatic during pregnancy and do not usually cause abortion.)

During a childbirth preparation class, the nurse teacher discusses the importance of the "spurt" of energy that occurs before labor. Why is it important to conserve this energy? Fatigue may increase the progesterone level. Extra energy decreases the intensity of contractions. Extra energy is needed to push during the first stage. Fatigue may influence pain medication requirements.

Fatigue may influence pain medication requirements. (Fatigue will interfere with the successful use of other coping strategies such as distraction; this may lead to the client's need for pain medication. Neither fatigue nor energy influences the progesterone level, which is diminished at this stage of the pregnancy. Energy will increase the intensity of contractions. The client does not push during the first stage of labor; pushing is done during the second stage.)

A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse's initial action be? Insert an intravenous (IV) catheter. Ask the client to sign a surgical consent form. Determine whether a family member is present. Ascertain the first day of the client's last menstrual period.

Insert an intravenous (IV) catheter. (The client is at risk for hypovolemic shock resulting from hemorrhage; administration of IV fluids is the priority. Asking the client to sign a surgical consent form, determining whether a family member is present, or ascertaining the first day of the client's last menstrual period is not the priority in an emergency situation.)

A client who has placenta previa now has started bleeding heavily and is being admitted to the high-risk unit. Why should the nurse place the client in the knee-chest position? It prevents shock It controls bleeding It keeps pressure off the cervix It moves the placenta off the cervix

It prevents shock (The knee-chest position shunts blood to the upper body and vital organs. The bleeding will continue, regardless of the client's position. Pressure on the cervix is believed to have no bearing on bleeding episodes. The placenta is implanted, and positioning will not move it off the cervix.)

A client with a history of a congenital heart defect is admitted to the birthing unit in early labor. Which position does the nurse encourage the client to assume? Supine Semi-Fowler Trendelenburg Left lateral recumbent

Semi-Fowler (The head of the bed should be elevated 45 degrees; this permits maximal chest expansion for ventilation. The laboring woman should not assume the supine position, because this would increase the risk of hypotension as a result of decreased venous return. The Trendelenburg position interferes with optimal cardiac function during labor and is contraindicated.)

Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process? Promoting vasodilation Cleansing perineal tissue Softening the incision site Tightening the rectal sphincter

Promoting vasodilation (Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.)

While a multiparous client is in active labor, her membranes rupture spontaneously. The nurse notes a loop of umbilical cord protruding from her vagina. What is the priority nursing action at this time? Monitoring the fetal heart rate Covering the cord with a saline dressing Pushing the cord back into the vaginal vault Holding the presenting part away from the cord

Holding the presenting part away from the cord (Holding the presenting part away from the cord must be done immediately to maintain cord circulation and prevent the fetus from becoming anoxic. The priority is maintaining cord circulation; although monitoring is important, it does not alter the emergency. Keeping the cord moist is secondary; keeping pressure off the cord is the priority. The cord should not be touched, because this increases pressure on the cord, further reducing oxygen flow to the fetus.)

A nurse is caring for a client with type 1 diabetes on her first postpartum day. While planning care for this client, what changes in insulin requirements does the nurse anticipate? Slowly decrease Quickly increase Suddenly decrease Usually remain unchanged

Suddenly decrease (Insulin requirements may decrease suddenly after delivery. During the first 24 to 48 postpartum hours insulin requirements will neither increase nor decrease slowly. Because the endocrine changes of pregnancy are reversed, insulin requirements do not usually remain unchanged in the postpartum period.)

What is the nurse's most important concern when caring for a client with a ruptured tubal pregnancy? Infection Hypervolemia Protein deficiency Diminished cardiac output

Diminished cardiac output (Uncontrolled bleeding causes decreased circulating blood volume, and therefore there is a decreased cardiac output. Infection may occur later but is not a problem at this time. There will be hypovolemia, not hypervolemia, because of a decrease in circulating blood volume resulting from hemorrhage. There are no data to justify the conclusion that the client has a protein deficiency.)

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure? Stroke Hemorrhage Precipitous labor Disseminated intravascular coagulation

Stroke (The likelihood of a stroke increases with a rising blood pressure reading. The degree of hypertension is not associated with hemorrhage. The course of labor is not affected by blood pressure changes except in the presence of abruptio placentae. Fluctuations in blood pressure do not affect the status of clotting factors.)

Laboratory studies reveal that a pregnant client's blood type is O and she is Rh-positive. Problems related to incompatibility may develop in her infant if the infant is what? Rh-negative Type A or B Born preterm Type O and Rh-positive

Type A or B (An ABO incompatibility may develop even in firstborn infants, because the mother has antibodies against the antigens of the A and B blood cells; these antibodies are transferred across the placenta and produce hemolysis of the fetal red blood cells. If the infant were AB, an incompatibility might also occur. Problems will not occur if the mother is Rh-positive and the infant is Rh-negative. A preterm birth will not produce an incompatibility; however, it may intensify problems if an incompatibility exists. If the infant is the same type and has the same Rh factor as the mother, there is no incompatibility.)

The nurse is caring for a client who is having a prolonged labor. The client is frustrated and very concerned because her labor is deviating from what she perceives as normal. After the nurse has acknowledged the client's feelings, what is the optimal next intervention? "I'll leave so you can talk to your partner." "I'll rub your back, and you tell me if it helps." "Let's talk some more about what's really bothering you." "Women usually become weary and frustrated during labor."

"I'll rub your back, and you tell me if it helps." (Rubbing the client's back and asking the client to report whether it helps offers comfort measures while giving the client an opportunity to verbalize her concerns further if she desires. Offering to leave so that the client may talk to her partner cuts off communication with the client. The client's focus is on her prolonged discomfort; there is no indication that she has other concerns at this time. The nurse should focus on the client, not on how other women may feel; this response may cut off communication.)

When checking the cervical dilation of a client in labor, the nurse notes that the umbilical cord has prolapsed. What is the priority nursing action? Taking the fetal heart rate Turning the client on her side Covering the cord with a sterile saline-soaked cloth Assisting the client into the Trendelenburg position

Assisting the client into the Trendelenburg position (Placing the client in the Trendelenburg position may prevent further prolapse and should relieve pressure on the umbilical cord. The fetal heart rate will be taken later; the priority is relieving pressure on the umbilical cord. Turning the client on her side will not relieve pressure on the umbilical cord, although it will promote placental perfusion. Covering the cord with a sterile saline-soaked cloth will not relieve pressure on the umbilical cord.)

After a client's membranes rupture spontaneously, the nurse visualizes the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority. Put a rolled towel under one hip and place the patient in the modified Sims position. Administer oxygen to the mother and monitor fetal heart tones. Call for assistance and don sterile gloves. Insert two fingers into the vagina and exert upward pressure against the fetal presenting part.

Call for assistance and don sterile gloves. Insert two fingers into the vagina and exert upward pressure against the fetal presenting part. Put a rolled towel under one hip and place the patient in the modified Sims position. Administer oxygen to the mother and monitor fetal heart tones. (This is an emergency, and additional personnel should be sought immediately. Sterile gloves should be donned before fingers are placed in the client's vagina. Exerting pressure against the presenting part relieves compression of the umbilical cord. The rolled towel and modified Sims position augment the relief of pressure against the cord. Oxygen administration increases the amount of oxygen perfusing the placenta. Fetal response to the event should be assessed with continuous monitoring of the fetal heart tone.)

The laboratory blood tests of a client at 10 weeks' gestation reveal that she has anemia. The client refuses iron supplements. The nurse teaches her that the best source of iron is liver. What other foods does the nurse encourage the client to eat? Select all that apply. Dark leafy green vegetables Legumes Dried fruits Broiled halibut Ground beef patty

Dark leafy green vegetables Legumes Dried fruits Ground beef patty (Excellent food sources of iron include liver, meats, whole grain or enriched breads, dark green leafy vegetables, legumes, and dried fruits. Halibut is a good source of protein, not iron.)

A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta? Put pressure on the fundus Ask the mother to bear down Have the mother breast-feed the newborn Place gentle continuous tension on the cord

Have the mother breast-feed the newborn (Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contractions. Fundal pressure should not be used; it could cause uterine prolapse. Having the mother bear down could cause uterine prolapse. If the placenta is still attached to the uterine wall, placing gentle continuous tension on the cord could cause the cord to detach from the placenta or cause uterine prolapse.)

A client with preeclampsia has a prescription for a magnesium sulfate infusion to be initiated. The nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply. Patellar reflex Output of urine Respiratory rate Body temperature Urine specific gravity

Patellar reflex Output of urine Respiratory rate (A baseline measurement of the patellar reflex should be obtained, because magnesium sulfate is a central nervous system depressant; an absence of patellar reflexes indicates magnesium sulfate toxicity. Magnesium sulfate is excreted by way of the kidneys; adequate urine output is necessary to prevent toxicity. Magnesium sulfate is a central nervous system depressant; a slowed respiratory rate is a sign of magnesium sulfate toxicity. Magnesium sulfate does not affect body temperature. The urine specific gravity test is not used before, during, or after magnesium sulfate therapy.)

A client with heart disease is admitted to the birthing suite. Which nursing intervention may help prevent the development of cardiac decompensation during her labor? Positioning her on the side with her head on a pillow Positioning her on the side with her shoulders elevated Administering the prescribed intravenous (IV) infusion of isotonic saline Administering the prescribed IV piggyback infusion of oxytocin

Positioning her on the side with her shoulders elevated (The side-lying position, particularly the left, takes the weight off large blood vessels, increasing blood flow to the heart; elevating the shoulders relieves pressure on the diaphragm. The client's head is too low in this position if she is only positioned with her head on a pillow; it should be elevated above the shoulders. Sodium leads to increased fluid retention; it is contraindicated in a client with heart disease; if it is prescribed, the nurse should question the primary healthcare provider. Administering the prescribed IV piggyback infusion of oxytocin is contraindicated unless some uterine inertia occurs; if it is prescribed, the nurse should question the primary healthcare provider.)

A pregnant woman with a history of heart disease visits the prenatal clinic toward the end of her second trimester. Which intervention does the nurse anticipate will be part of this client's care plan? Preparation for a cesarean birth Bed rest during the last trimester Prophylactic antibiotics at the time of birth Increasing dosages of cardiac medications as pregnancy progresses

Prophylactic antibiotics at the time of birth (Prophylactic antibiotics are given to clients with heart disease to reduce their risk for bacterial endocarditis. A vaginal birth, with a shortened second stage and an assisted birth involving forceps or vacuum extraction, is preferred. The data do not indicate which class of heart disease the client has; if it is class I and there is no cardiac decompensation, activities may be restricted; however, bed rest is not necessary. Increasing the dosages of the client's cardiac medications may or may not be necessary; dosages are based on each individual's response to the stress imposed by pregnancy.)

A client with a history of phenylketonuria (PKU) who was maintained on a low-phenylalanine diet until 9 years of age is pregnant. What is most important for the nurse to discuss with this client? The infant may be developmentally disabled because of her history of PKU. Reinstitution of the low-phenylalanine diet will protect her baby from the disorder. The fetus is not at risk prenatally but will require immediate care at birth to prevent PKU. The client should avoid phenylalanine even when she is not pregnant so her body is able to support a pregnancy.

Reinstitution of the low-phenylalanine diet will protect her baby from the disorder. (The fetus is at risk from a build-up of metabolites in the PKU-affected mother if the prescribed diet is not followed. The infant will not be affected if a low-phenylalanine diet is maintained by the mother during pregnancy; also, the infant may inherit PKU by way of an autosomal recessive gene. The client should restart a phenylalanine-restricted diet when planning to become pregnant and continue it throughout pregnancy.)

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. Restricting visitors Limiting fluid intake Preparing for a precipitate birth Maintaining a quiet environment Keeping magnesium gluconate at the bedside

Restricting visitors Maintaining a quiet environment (Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and therefore the risk of seizures. Fluid intake should not be restricted. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.)

A pregnant client is concerned that she may have been infected with human immunodeficiency virus (HIV). Which information should a nurse include when counseling this client regarding HIV testing? Select all that apply. The risks of passing the virus to the fetus What positive or negative test results indicate The risk factors for contracting HIV The need for pregnant women to be tested for HIV The emotional, legal, and medical implications of test results

The risks of passing the virus to the fetus What positive or negative test results indicate The emotional, legal, and medical implications of test results (Understanding the risks of transmission, along with treatment options if the client is HIV positive, will help her make appropriate decisions regarding testing. Some women are confused about what positive or negative means in regard to test results. Explaining this in pretest counseling and again when results are given decreases unnecessary stress and misunderstanding. Because of the stigma of the disease and the possible effects on insurance and medical care, clients should receive adequate counseling regarding implications. Although it may be helpful for primary healthcare providers to know if a client is at risk for HIV, the client is not required to disclose this information. HIV testing of pregnant women is not required; however, it is highly recommended by most primary healthcare providers.)

A client at 36 weeks' gestation is admitted to the high-risk unit with heavy bleeding because of complete placenta previa. Why does the nurse place the client in a lateral Trendelenburg position? To prevent shock To control bleeding To keep pressure off the cervix To move the placenta off the cervix

To prevent shock (The Trendelenburg position shunts blood to the upper body and vital organs. The Trendelenburg position will not help control the bleeding. Pressure on the cervix is thought to have no bearing on bleeding episodes. In late pregnancy the placenta does not change its location in the uterus. Also, the Trendelenburg position cannot move the placenta from the cervix.)

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include? Withholding oral fluid intake Discussing the need for formula feeding Obtaining permission for a paracervical block Applying moist compresses to the perineal area

Withholding oral fluid intake (Withholding oral intake of fluids is part of the preparation for a cesarean birth. This client has active herpes, which can be transmitted to the infant during a vaginal birth. A client with herpes may breast-feed. A paracervical block is not used for a planned cesarean birth. Herpes lesions should be kept as dry as possible.)