REPRODUCTION & CLOTTING UNIT 3 Sem 4

HEPARIN

(Help prevent micro-clots) -Only if benefits (reduce clots) outweigh risks (further bleeding) -Often restricted to if have not responded to tx of the underlying Dz or replacement of coagulation factors & platelets -Chronic DIC does not respond to oral anticoagulants (But can be controlled w long-term use of heparin)

Eclampsia Immediate Care!

-Side lying -Padded side railes w pillow/blankers -O2 -Suction if needed -Do not retrain -Stay with patient

Diagnosis of severe preeclampsia...what will the protein levels be?

5 grams protein in a 24 hr urine collection or a dipstick of 3+

Match the following s/sx for each abruption: 1. Marginal 2. Partial/central 3. Complete A. Lack of fetal heart tones . B. Blood noticed of vaginal exam. C. Pain is the primary symptom..

ANS: 1. B 2.C 3.A *Marginal: Blood noticed on vaginal exam. *Partial/central: Pain is the primary sx. *Complete: Lack of fetal heart tones.

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS: 21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.

Select all the signs and symptoms associated with placenta previa: a. Painless bright red bleeding b. Concealed bleeding c. Hard, tender uterus d. Normal fetal heart rate e. Abnormal fetal position f. Rigid abdomen:

ANS: A, D, E These are all sign and symptoms of placenta previa. The other options are associated abruptio placentae.

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)? a. Bleeding time of 10 minutes b. Presence of fibrin split products c. Thrombocytopenia d. Hyperfibrinogenemia

ANS: B Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

Thrombocytopenia

Abnormally low levels of platelets, in blood. ➔ Normal human platelet count is from 150,000 to 450,000 platelets per microliter of blood.

Magnesium Antidote

Calcium gluconate or Calcium chloride (IV)

Disseminated Intravascular Coagulation (DIC): Risk Factors

DIC is NOT a disease but it occurs d/t an underlying condition or disease: *Trauma (MVA) *Obstetric complications -Abruptio Placentae!!! -Intrauterine fetal death (Marginal) *Infection/Sepsis *Toxins *Allergic reaction *Malignancy *Shock *Amniotic Fluid Embolism *Liver Dz

Postpartum Hemorrhage (PPH) Risk Factors (Blood & Clots)

Dark red blood (Venous blood): probably ok may be from varices or superficial lacerations of the birth canal. Bright red blood (Arterial blood): NOT OK; may indicate deep lacerations of the cervix. Spurts of blood w/ clots: can indicate partial placental separation. Failure of blood to clot or remain clotted: indicates a pathologic condition or coagulopathy such as DIC Hematomas -Pt will be complaining of pain

Most often definite treatment for HELLP?

Delivery of baby

What's hypertension (HTN) ?

Systolic > 140 or Diastolic >90

Magnesium Sulfate (CNS depressant)

-Used to treat/reduce risk/prevent seizures, not to decrease BP -Can prolong labor -Therapeutic level 4-7 (Ex of good findings: DTR +2; Diuresis) *Drug of choice for treatment of seizure activity caused by severe pre-eclampsia Chose over diazepam bc magnesium sulfate reduces risks of aspiration (by not reducing gag reflex) *High alert med: can cause harm ...NEVER abbreviate magnesium sulfate as MgSO4 anywhere in medical record *Almost always administered IV or as a piggyback via pump

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? a. Headache and decreased output. b. Puffy feet. c. Hemorrhoids and vaginal discharge. d. Backache

ANS: A Headache and decreased output are signs of preeclampsia. It is important for the test taker to realize that, although some symptoms like puffy feet may seem significant, they are normal in pregnancy, while other symptoms like headache, which in a nonpregnant woman would be considered benign, may be potentially very important in a pregnant woman.

A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome? a. Rise in serum creatinine b. Drop in serum protein c. Resolution of thrombocytopenia d. Resolution of polycythemia

ANS: C

Preeclampsia Manifestations

P: Proteinuria R: Rising BP (hypertension) E: Edema -Severe headache -RUQ or Epigastric Pain -Visual disturbances -Low UO (urine output <30 ml/hr) -Weight gain (Rapid...ex 6lbs in one month) -Hyperreflexia -Decreased renal blood flow & GFR -Edema

Preeclampsia Pathology

Pathology is not completely known. *Placenta is the root cause *Defective Spiral Artery Remodeling *Systemic Vasoconstriction & endothelial dysfunction

HELLP Syndrome Lab findings

Platelets (norm 150-450K) DECREASED. Hgb (norm 12-16) DECREASED. Hct (norm 37-47%) DECREASED. RBC: Breakdown or RBC Fibrinogen (norm 200-400) DECREASED. FSPs (norm <10) PRESENT LDH (norm 100-190) INCREASED. AST (norm 12-37) INCREASED. ALT (norm 13-69) INCREASED. BUN (norm 10-20) INCREASED. CREAT (norm 10-20) INCREASED. Creatine Clearance (norm 85-125) DECREASED. Protein Creatine Ratio ABSENT or INCREASED. (May not have s/sx of severe preeclampsia...BP may only be mildly elevated) Uric Acid (2-6.6) INCREASED ">10" Bilirubin total (norm 0.3-1.0) INCREASED ">1.2" Burr cells or Schistocytes (norm absent) PRESENT! FHR

Superimposed Preeclampsia

*Chronic HTN in Assoc w/ preeclampsia (develop preeclampsia during pregnancy) *Associated with adverse maternal or fetal outcomes *Difficult to dx

Chronic Essential Hypertension

*HTN in a pregnant woman present BEFORE pregnancy *Or HTN that was diagnosed during pregnancy that persists longer than 12 weeks postpartum

A client at 28 weeks' gestation visits the clinic for a routine examination. Which finding is of greatest concern to the nurse? a. Puffy fingers b. Glycosurial+ c. Proteinuria1+ d. Dependent edema

ANS: A One sign of mild preeclampsia is puffiness of the fingers, eyes, and face. Glycosuria is a common finding in pregnancy; an increased glomerular filtration rate in conjunction with decreased capacity of the tubules to reabsorb glucose may cause spillage of glucose into urine. Minimal proteinuria may occur in a healthy pregnancy; the amount of protein that must be filtered exceeds the ability of the tubules to absorb it, causing small amounts to be lost in the urine. Venous obstruction from the gravid uterus decreases blood flow to the heart; as a result, fluid pools in the lower extremities; dependent edema is expected.

The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is: a. hypertension. b. hyperemesis gravidarum. c. hemorrhagic complications. d. infections.

ANS: A Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common

Which signs or symptoms would the client display if she were developing hemolysis? a. Headache b. Constipation c. Abdominal Pain. d. Vaginal bleeding. e. Flulike symptoms.

ANS: A, C, E Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia

A 29-week-gestation woman diagnosed with severe preeclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the last 2 days. Which of the following signs/symptoms would the nurse also expect to see? a. Fundal height of 32 cm. b. Papilledema. c. Patellar reflexes of +2. d. Nystagmus.

ANS: B The nurse would expect to see papilledema. Intracranial pressure (ICP) is present in a client with severe preeclampsia because she is third 3rd spacing large quantities of fluid. As a result of the ICP, the optic disk swells and papilledema is seen when the disk is viewed through an ophthalmoscope.

A patient is receiving magnesium sulfate for severe preeclampsia. The nurse must notify the attending physician immediately of which of the following findings? a. Patellar and biceps reflexes or +4 b. Urinary output or 50 mL/hr c. Respiratory rate of 10 rpm d. Serum magnesium level of 5 mg/dl

ANS: C

When counseling a preeclamptic client about her diet, what should the nurse encourage the woman to do? a. Restrict sodium intake. b. Increase intake of fluids. c. Eat a well-balanced diet. d. Avoid simple sugars.

ANS: C It is important for the client to eat a well-balanced diet. Sodium restriction is not recommended. There is no need to increase fluid intake. Although not the most nutritious of foods, there is no need to restrict the intake of simple sugars.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? a. Low serum creatinine. b. High serum protein. c. Bloody stools. d. Epigastric pain

ANS: D Epigastric pain is associated with the liver involvement of HELLP syndrome. : When the liver is deprived of sufficient blood supply, as can occur with severe preeclampsia, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.

Fetal complications in Abruptio Placentae?

(r/t severity & timing of the hemorrhage) -IUGR -Oligohydramnios -Preterm birth -Hypoxemia -Stillbirth

Gestational Hypertension

*AFTER 20 wks of pregnancy in previously normotensive women w/o proteinuria *Does NOT persist longer than 12 wks postpartum

HELLP Syndrome Risk Factors

*Preeclampsia (HTN) *Caucasian women (note: preeclampsia occurs more often in African Americans) Complications increases risk for HELLP *Maternal death *Adverse perinatal outcomes: -PE -Acute Renal Failure -DIC -Placental Abruption -Liver hemorrhage or failure -ARDS -SEPIS -STROKE

Chronic Hypertension Disorders (BEFORE pregnancy or BEFORE 20 weeks!)

1st trimester -Cannot get great BP measure d/t N/V *Chronic Hypertension *Superimposed preeclampsia

Gestational Hypertension disorders (AFTER 20 weeks' gestation)

2nd & 3rd trimester -Look at BP in 2nd trimester: baseline BP -3rd trimesters expect highest BP -If Dz develops after 34 wks getstion: Women should give birth PROMPTLY *Gestational Hypertension *Preeclampsia *Eclampsia

The client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? a. Oozing blood from the IV catheter site b. Sudden onset of chest pain and frothy sputum c. Foul smelling, concentrated urine d. A reddened, inflamed central line catheter site.

ANS: A S/sx of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from everybody orifice and into the tissues.

Severe Preeclampsia Manifestations

-Severe/Worsening HA -Severe Epigastric/RUQ pain -Scotoma -Photophobia -Double vision/Blurred vision -AMS (Altered mental status) *Signs you may see in preeclamptic patient who is about to have a seizure *Worsening preeclampsia is accompanied by hyperreflexia = Seizures

Which collaborative treatment would the nurse anticipate in the client diagnosed with DIC? a. Administer oral anticoagulants. b. Prepare for plasmapheresis. c. Administer fresh frozen plasma. d. Calculate the intake and output.

ANS: C Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets.

A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure client safety. a. Assess uterine contractions continuously b. Assess FHR continuously c. Assess urinary output d. Assess respiratory rate

ANS: D

Preeclampsia definition

HTN & proteinuria after 20 wks of pregnancy in previously NORMOTENSIVE women (If absence of proteinuria: The onset of HTN along w/ thrombocytopenia, renal insufficiency, impaired liver function, PE, or cerebral or visual s/sx is also known as preeclampsia)

HELLP in detail

(H: Hemolysis) Urinalysis: - One of the most common diagnostic tests that determine the presence of protein in the urine -Usually indicative of pregnancy induced HTN -Elevated serum bilirubin (>1.2) (EL: Elevated Liver Enzymes) Liver Function: -AST or ALT (>2x upper limit of normal) -LDH (>2 upper limit of normal) (LP: Low Platelet count) CBC: - Platelet count (<100,000/mm3) -Abnormal peripheral blood smear (schistocytes, burr cells) -Drop in HGB or HCT unrelated to blood loss -Low serum haptoglobin

Placenta Previa Manifestations

*Condition in which the placenta lies very low in the uterus and covers all or part of the cervix. -Light/bright red bleeding -No pain -Uterus is often relaxed -May be no changes in fetal HR

Leading cause of early PPH a. Uterine atony b. Subinvolution of the Uterus c. Pelvic infection d. Retained placental fragments

ANS: A

Differences between: Abruptio Placentae (Placental Abruption) VS Placenta Previa

Main difference: There is PAIN in abruptio placenta, and DARK bleeding Abruptio Placentae -Sudden & stormy -Pain severe, steady -Dark red vaginal bleeding -Uterus rigid, board like *FHR: present or absent, May be severe variables, loss of variability, late decelerations, bradycardia, tachycardia Placenta Previa -Light/bright red bleeding -NO pain -Uterus is often relaxed -May be no changes in fetal HR

Abruptio Placentae (Placental Abruption) Treatment

➢ IV therapy: -Once starts to bleed, Dr order large gauge catheter to replace fluid losses ➢ Oxygen -Via face mask -Prevent fetal anoxia ➢ Fibrinogen determination -Taken several times before birth to detect DIC

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. elevated D-dimers b. elevated fibrinogen c. reduced prothrombin time (PT) d. reduced fibrin degradation products (FDPs)

ANS: A The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to: a. Assess fetal heart rate (FHR) and maternal vital signs. b. Perform a venipuncture for hemoglobin and hematocrit levels. c. Place clean disposable pads to collect any drainage. d. Monitor uterine contractions.

ANS: A Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.

Abruptio Placentae (Placental Abruption) TYPES of SEPERATIONS

MARGINAL: -Placenta separates at its edges -Pain -Blood passes between fetal membranes & uterine wall -Blood escapes vaginally (externally bleeding) PARTIAL/CENTRAL: -Placenta separates centrally -Blood trapped between placenta & uterine wall.... won't see bleeding. -Concealed bleeding -Pain is the primary symptom with this particular type of abruption COMPLETE "TOTAL": -TOTAL separation -Massive bleeding OR Concealed -Lack of fetal heart tones because there is no longer any circulation

Postpartum Hemorrhage (PPH) Magnesium Sulfate

*Magnesium sulfate -Acts as a muscle relaxer → thus at risk for uterine atony- Commonly given if have significant elevations in BP associated w/ PIH- Antidote: Calcium gluconate

Postpartum Hemorrhage (PPH) LATE (Secondary) CLASSIFICATION

*Occurs more than 24 hrs but less than 6 wks after the birth *Can be a result of Subinvolution of the uterus, Endometritis, or Retained placental fragments

HELLP Syndrome Pathology

*Occur as result of arteriolar vasospasm, endothelial cell dysfunction w fibrin deposits, adherence platelets in blood vessels ❖ RBCs are damaged as they pass through narrowed blood vessels and become hemolyzed, resulting in decreased RBC and platelet count and hyperbilirubinemia ❖ Endothelial damage & fibrin deposits in the liver lead to impaired liver function causing hemorrhagic necrosis.

Abruptio Placentae (Placental Abruption) EXPECTANT Management

*Depends on blood loss severity; fetal maturity/status. *For fetus <34- 20 wks of gestation & if mom/fetus stable Mom: Monitor close bc abruption may extend any time. Fetus: Assess regularly for evidence of appropriate growth (risk for IUGR). -Assessments of fetal well-being regularly (Nonstress testing, Biophysical profile) Corticosteroid: for fetal lung maturity

Severe Preeclampsia (w/ features) & Severe Gestational HTN Management

*Hospitalized immediately: thorough evaluation of maternal-fetal status- *Magnesium sulfate: prevent eclamptic seizures *Antihypertensive meds: if necessary to lower severe levels of HTN. *Maintain bedrest *Side rails up *Quiet/dark place *Emergency drugs *O2, suction (check equipment) *Reduce risk for PE: Total IV & oral fluid does not exceed 125 ml/hr *Hemodynamic Monitor w PA cath (Swan-Ganz) evaluate: CVP & PAP -only if oliguria unresponsive to fluid

DIC

A pathologic form of diffuse clotting that consumes large amounts of clotting factors and causes widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome

Which of the following is most likely NOT a sign of abruptio placenta? a. Sudden onset of painless vaginal bleeding b. Board-like abdomen with severe pain c. Sudden onset of dark red vaginal bleeding with mild pain d. Severe pain with dark red bleeding

ANS: A *Tip: RE-READ your question multiple times, don't make a silly mistake.

Post-Partum Induced Hypertension (PIH) Define & Manifestations

Classic signs of PHI: -Clonus -Scotoma -Hyperreflexia -Periorbital edema -Proteinuria (Uric acid may be seen)

Disseminated Intravascular Coagulation (DIC) Lab findings (SCREENING TEST)

PT (norm 11-14): PROLONGED PTT (norm 25-35): PROLONGED APTT (norm ): PROLONGED Thrombin Time: PROLONGED Fibrinogen (norm 200-400): REDUCED Platelets (norm 150-450K): REDUCED

Preeclampsia Lab Findings

Platelets (norm 150-450K) DECREASED. Hgb (norm 12-16) may INCREASED. Hct (norm 37-47%) may INCREASED Fibrinogen (norm 200-400) INCREASED. FSPs (norm <10) ABSENT or PRESENT LDH (norm 100-190) INCREASED AST (norm 12-37) INCREASED ALT (norm 13-69) INCREASED BUN (norm 10-20) INCREASED CREAT (norm 10-20) INCREASED Creatine Clearance (norm 85-125) INCREASED "120-180" Protein Creatine Ratio INCREASED ">0.3" Uric Acid (2-6.6) INCREASED ">5.9" Bilirubin total (norm 0.3-1.0) UNCHANGED or INCREASED Burr cells or Schistocytes (norm absent) ABSENT FHR

Fetal complications in preeclampsia w severe features?

*Intrauterine growth restriction *Abnormal FHR & pattern *Iatrogenic preterm birth *Placental abruption

Postpartum Hemorrhage (PPH) Define

*Loss of >500 mL of blood after vaginal birth and 1000 mL or more after cesarean birth *10% change in HCT from time of admission to the birthing *Lead cause of maternal morbidity/mortality in the U.S and throughout the world *Occur with little warning *Classified as early or late (in respect to birth )

Post-Partum Induced Hypertension (PIH) Management & Treatment

*Magnesium Sulfate: commonly given if elevated BP *Delivery of baby (only cure)

MANAGMENT & TYPES OF TRANSFUSIONS

1. Respiratory (O2 may need) 2.Volume replacement/blood products (may needed) -Blood products w/ platelet support -Cryoprecipitate -FFP: if life threatening hemorrhage. *Fresh frozen plasma (FFP): -replaces ALL Factors (except for platelets) & provides a source of Antithrombin (IF sx of thrombosis: Treat w Anticoagulation "Heparin or Lovenox" → only when benefits outweigh risks) *Platelets: -When platelets are < 20,000 (thrombocytopenia) or < 50,000 & bleeding seen

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: a. bleeding. b. intense abdominal pain. c. uterine activity. d. cramping.

ANS: B Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

Magnesium Sulfate Dose

~Initial loading dose: 4-6g is infused over 15-30 mins ~Maintain dose: 2g/hr to maintain a therapeutic serum magnesium level of 4-7 mEq/L (typically 40grams of magnesium is deluded into 1000ml or lactated ringer yielding 1 gram of magnesium in each 25ml of fluid administered by pump at 2 grams/hour)

Abruptio Placentae (Placental Abruption) ACTIVE Management >34 weeks gestation to term

*Immediate birth/DELIVERY is management of choice (if at birth or bleeding mod-severe, mom/fetus are in jeopardy) *Fetus at term >34 wks gestation or if bleeding mod- severe or mom/fetus in jeopardy. -Insert large-bore IV (16 -18g) -Mom: Monitor V/S frequent to observe for sx of declining hemodynamic status (Increase pulse; decrease BP) -Labs (HCT or HCG; Clotting studies) -Continuous EFM (mandatory) -Insert indwelling catheter: assess UO & indirect measure mom's organ perfusion. -Fluid volume replacement (may need) -Administration of blood products (to correct any coagulation defects). -Vaginal birth preferable (C-sec if need) Cesarean: AVOID if severe/ uncorrected coagulopathy *risk uncontrolled bleeding -Patient education/Emotional support:

Couvelaire Uterus

*Uterus purple or blue rather than its usual "bubble-gum pink" color, and contractility is lost. *Uterus is tense/rigid/hard/board like/no bleeding *Occurs when blood accumulated between separated placenta/uterine wall produced. *Risk for Maternal Hypovolemia: -Shock -Oliguria -Anuria

Hemophilia

-Inherited bleeding disorder in which the blood does not clot properly. Hemophilia A. (most common) Caused by deficiency in factor VIII, also known as "classic hemophilia. "

Postpartum Hemorrhage Management

Important to note BLOOD COLOR & CONSITENCY, and STAGE OF LABOR (From birth of infant until) 1. First intervention: ASSESS UTERUS (if boggy perform uterine massage) *Each birthing facility should have obstetric hemorrhage team that is called into action when hemorrhage occurs. *Safety bundle for OB hemorrhage. -READINESS -RESPONSE -RECOGNITION/PREVENTION -REPOSITIONING/SYSTEMIC LEARNING

Nonstress test (NST)

Screening test used in pregnancy. -Cardiotocograph is used to monitor the FHR

Abruptio Placentae (Placental Abruption) Risk Factors

➔ Maternal HTN (most consistent ) ➔ Cocaine use ➔ Blunt abdominal trauma (MVA/batter) -Direct trauma to the abdomen ➔ Short umbilical cord -Placenta separation (esp if trauma occurs) ➔ Cigarette smoking ➔ Hx of abruption in previous pregnancy ➔ High parity (birth multiple times) ➔ Premature rupture of membranes ➔ Presence of thrombophilia ➔ Advanced maternal age >35 ➔ Chorioamnionitis: - Infection of fetal membranes & fluid may lead to premature placental separation

Petechiae

A plural petechiae, small (1-2 mm) red or purple spot on the skin, caused by minor bleed from broken capillary blood vessels. ➔ Petechia refers to one of 3 descriptive types of bleeding into skin differentiated by size. Other two being purpura & ecchymosis. ➔ Petechiae are PINPOINT, round spots that appear on the skin as a result of bleeding ➔ Clusters; may look like a rash. ➔ Flat to touch, they don't lose color when pressed. Sometimes appear on the inner surfaces of the mouth or eyelids.

Postpartum Hemorrhage (PPH) EARLY (Acute/Primary) CLASSIFICATION

*Occurs within 24 hrs of the birth *Greatest risk for early PPH is during 1st hour after birth *Uterine atony is the lead cause of early PPH (uterus is "overstretched") → perform fundal massage!!

Disseminated Intravascular Coagulation (DIC) Treatments.

*Treat the underlying cause! *Transfusions: -Packed RBC's -Fresh Frozen plasma (FFP) -Platelets

Postpartum Hemorrhage (PPH) Risk Factors (Uterine)

*Uterine atony (common in early PPH) -uterus fails to contract after the delivery of the baby→ it may feel "boggy" *Lacerations of the Genital Tract -Presence of a firm/contracted uterine fundus *Retained Uterus *Inversion of Uterus ( emergency) -Presence of a large, red, rounded mass protruding from the introitus. (incomplete, complete, prolapsed) *Subinvolution of Uterus (common late PPH)

Which of the following signs or symptoms would the nurse expect to see in a woman with concealed abruptio placentae? a. Increasing abdominal girth measurements b. Profuse vaginal bleeding c. Bradycardia with an aortic thrill d. Hypothermia with chills

ANS: A

A woman at 37 weeks of gestation is admitted with a placental abruption after a motor vehicle accident. Which assessment data are most indicative of her condition worsening? a. Pulse (P) 112, respiration (R) 32, blood pressure (BP) 108/60; fetal heart rate (FHR) 166--178 b. Pulse (P) 98, R 22, BP 110/74; FHR 150--162 c. Pulse 88, R 20, BP 114/70; FHR 140--158 d. Pulse 80, R 18, BP 120/78; FHR 138--150

ANS: A Bleeding is the most dangerous problem, which impacts the mother's well-being as well as that of her fetus. The decreasing blood volume would cause increases in pulse and respirations and a decrease in blood pressure. The fetus often responds to decreased oxygenation as a result of bleeding, causing a decrease in perfusion. This causes the fetus' heart rate to increase above the normal range of 120--160 beats per minute. The other options have measurements that are in the "normal" range and would not reflect a deterioration of the patient's physical status.

A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? a. Swelling of the calf in one leg b. Prolonged clotting times c. Decreased platelet count d. Petechiae, oozing from injection sites, and hematuria

ANS: A DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

The nurse explains to a group of nursing students how magnesium sulfate treats severe preeclampsia. Which response by a student indicates effective teaching? a. "It blocks neuromuscular transmissions". b. "It provides analgesia for the client in labor". c. "It increases the quantity of acetylcholine." d. "It improves the quality of uterine contractions".

ANS: A Eclamptic seizures may be prevented with the administration of IV magnesium sulfate, which is a CNS depressant that block neuromuscular transmission.

You're performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the following assessment findings would you immediately report to the physician? a. Oozing around IV site b. Tender uterus c. Hard abdomen d. Vaginal bleeding

ANS: A Oozing around the IV site can indicate the patient is entering into DIC (disseminated intravascular coagulation) because clotting levels have been depleted. Therefore, the MD should be notified. Option B, C, and D are findings found in this condition, but Option A is a SEVERE complication that can develop from it.

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/mL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/mL unless the patient is actively bleeding. Therefore, the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? a. Administration of blood b. Preparation of the patient for invasive hemodynamic monitoring c. Restriction of intravascular fluids d. Administration of steroids

ANS: A Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a patient with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? a. Administration of blood b. Preparation of the client for invasive hemodynamic monitoring c. Restriction of intravascular fluids d. Administration of steroids

ANS: A Primary medical management in all cases of DIC involves correction of the underlying cause, volume. replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a client with DIC. because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

An appropriate nursing intervention for a patient whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated

In caring for an immediate after birth patient, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder: a. disseminated intravascular coagulation (DIC). b. amniotic fluid embolism (AFE). c. hemorrhage. d. HELLP syndrome.

ANS: A The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the after birth patient. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

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. a. Patellar reflex b. Output of urine c. Respiratory rate d. Body temperature e. Urine specific gravity

ANS: A, B, C 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 pregnant patient in the first trimester reports spotting of blood with the cervical os closed and mild uterine cramping. What does the nurse need to assess? Select all that apply. a. Progesterone levels b. Transvaginal ultrasounds c. Human chorionic gonadotropin (hCG) measurement d. Blood pressure e. Kleihauer-Betke (KB) test reports

ANS: A, B, C The spotting of blood with the cervical os closed and mild uterine cramping in the first trimester indicates a threatened miscarriage. Therefore the nurse needs to assess progesterone levels, transvaginal ultrasounds, and measurement of hCG to determine whether the fetus is alive and within the uterus. Blood pressure measurements do not help determine the fetal status. KB assay is prescribed to identify fetal-to-maternal bleeding, usually after a trauma.

Select all the patients below who are at risk for developing placenta previa: a. A 37-year-old woman who is pregnant with her 7th child. b. A 28-year-old pregnant female with chronic hypertension. c. A 25-year-old female who is 36 weeks pregnant that has experienced trauma to abdomen. d. A 20-year-old pregnant female who is a cocaine user.

ANS: A, D Risk factors for developing placenta previa include: Maternal age >35 years old, multiples (twins etc.), already had a baby, drug use: cocaine or smoking, surgery to the uterus that will leave scarring: fibroid removal, c-section.

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

ANS: A, D 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 nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What adverse effects indicate that the serum magnesium level may be excessive? Select all that apply. a. Absence of the knee-jerk reflex b. Urine output of 100 mL/hr c. Blood pressure of 140/90 mm Hg d. Apical pulse of 80 beats/min e. Respiratory rate of 11 breaths/min

ANS: A, E An absence of the knee-jerk reflex is a manifestation of hyporeflexia; it is a possible indication of magnesium sulfate toxicity. A respiratory rate of 11 breaths/min is cause for concern; any rate slower than 12 breaths/min is a sign of magnesium sulfate toxicity. A urinary output of 100 mL/hr is adequate; output of less than 30 mL/hr indicates inadequate excretion of magnesium sulfate and the potential for toxicity. The maternal blood pressure is not directly related to magnesium sulfate administration or toxicity; however, decreased blood pressure indicates that the treatment has been effective. A pulse rate of 80 beats/min is an expected pulse rate, not an indicator of toxicity

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

ANS: B

Which maternal condition always necessitates delivery 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 delivery occurred. If the mother has stable vital signs and the fetus is alive, a vaginal delivery can be attempted in cases of partial abruptio placentae. If the fetus has died, a vaginal delivery 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.

A woman with severe preeclampsia is being treated with an intravenous infusion of magnesium sulfate. This treatment is considered successful if: a. blood pressure is reduced to prepregnant baseline. b. seizures do not occur. c. deep tendon reflexes become hypotonic. d. diuresis reduces fluid retention.

ANS: B Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.

What is the priority nursing action when caring for a client with DIC? a. Monitor for Homans sign. b. Avoid giving IM injections. c. Take temperature via the rectal route. d. Apply sequential compression stockings.

ANS: B Massive amount of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis.

A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of: a. placenta previa. b. vasa previa. c. severe abruptio placentae. d. disseminated intravascular coagulation (DIC).

ANS: B Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a board-like uterus).

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: a. Complete bed rest for the remainder of the pregnancy b. Delivery of the fetus c. Strict monitoring of intake and output d. The need for weekly monitoring of coagulation studies until the time of delivery

ANS: B The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

A 36-year-old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with abruptio placentae? Select all that apply. a. Decrease in fundal height. b. Hard abdomen c. Fetal distress d. Abnormal fetal position e. Tender uterus:

ANS: B, C, E Option A is wrong because there may be an INCREASE in fundal height (not decrease) due to concealed bleeding. Option D is wrong because this tends to occur in placenta previa because the placenta attaches too low in the uterus at the cervical opening.

A pregnant patient with chronic hypertension is at risk for placental abruption. Which symptoms of abruption does the nurse instruct the patient to be alert for? Select all that apply. a. Weight loss b. Abdominal pain c. Vaginal bleeding d. Shortness of breath e. Uterine tenderness:

ANS: B, C, E The nurse instructs the pregnant patient to be alert for abdominal pain, vaginal bleeding, and uterine tenderness as these indicates placental abruption. Weight loss indicates fluid and electrolyte loss and not placental abruption. Shortness of breath indicates inadequate oxygen, which is usually seen in a patient who is having cardiac arrest.

Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A positive. What nursing interventions below will you include in the patient's care? Select all that apply: a. Routine vaginal examinations b. Monitoring vital signs c. Administer RhoGAM per MD order. d. Assess internal fetal monitoring. e. Placing patient on side-lying position. f. Monitoring pad count g. Monitoring CBC and clotting levels:

ANS: B, E, F, G term-108 Option A is WRONG because vaginal exams are avoided to prevent causing damage to the placenta presenting at the cervical opening. Option C is WRONG because the patient is A positive and does NOT need RhoGAM, which is for patients who are RH negative. Option D is WRONG because external monitoring should be used NOT internal, which can damage the placenta at the cervical opening.

Which condition would not be classified as a bleeding disorder in late pregnancy? a. Placenta previa. b. Abruptio placentae. c. Spontaneous abortion. d. Cord insertion ANS: C

ANS: C

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placenta. Which of the following assessment findings would the nurse expect to note if this condition is present? a. Absence of abdominal pain b. A soft abdomen c. Uterine tenderness/pain d. Painless, bright red vaginal bleeding

ANS: C In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by the failure of the uterus to relax to constrict blood vessels and control bleeding.

DIC is a disorder in which: a. The coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels. b. An underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts. c. A disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage. d. An inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

ANS: C In disseminated intravascular coagulation (DIC), the coagulation process is stimulated, with resultant thrombosis and depletion of clotting factors, which leads to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? a. administer heparin. b. administer whole blood. c. treat the causative problem. d. administer fresh frozen plasma

ANS: C Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

Which condition indicates concealed hemorrhage when the patient experiences an abruptio placentae? a. Decrease in abdominal pain. b. Bradycardia c. Hard, board-like abdomen d. Decrease in fundal height

ANS: C 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, board-like abdomen. Abdominal pain may increase. The patient will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height will increase.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Give the PRN diphenhydramine. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Draw blood for a new type and crossmatch.

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.

ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom's circulation, leading to clot formation and then clotting factor depletion. a. Placenta previa, fibrinogen. b. Placenta previa, platelets. c. Abruptio Placentae, fibrinogen. d. Abruptio Placentae, thromboplastin.

ANS: D

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? a. Gravida III with twins b. Gravida V with endometriosis c. Gravida II who had a 9-lb baby. d. Gravida I who has had an intrauterine fetal death:

ANS: D (Remember Subacute DIC risk factor!) Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that DIC is occurring? a. Boggy uterus b. Hypovolemic shock c. Multiple vaginal clots d. Bleeding at the venipuncture site.

ANS: D Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.

The nurse is providing care to a client with preeclampsia who is receiving magnesium sulfate 2 g/hr. The nurse receives a call from the laboratory technician indicating that the client has a magnesium level of 6.4 mEq/L (0.30 mmol/L). What is the next nursing action? a. Stopping the infusion b. Assessing the client's deep tendon reflexes c. Assessing the client's level of consciousness. d. Documenting the level in the client's electronic medical record:

ANS: D Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEq/L (0.28 to 0.44 mmol/L). The nurse must constantly assess the client for a toxic level of magnesium, which can depress the central nervous system and slow the respiratory rate, alter the level of consciousness, and cause deep tendon reflexes to diminish or disappear.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response would be to: a. prepare the woman for imminent birth. b. notify the woman's primary health care provider. c. document the characteristics of the fluid. d. assess the fetal heart rate and pattern. ANS: D

ANS: D The umbilical cord may prolapse when the membranes rupture. The fetal heart rate and pattern should be monitored closely for several minutes immediately after ROM to ascertain fetal well-being, and the findings should be documented.

The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? a. Boggy uterus b. Hypovolemic Shock c. Multiple vaginal clots. d. Bleeding at the venipuncture site.

ANS: D Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.

A placenta previa in which the placental edge just reaches the internal os is more commonly known as: a. total. b. partial. c. complete. 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. When the patient experiences a partial placenta 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 placenta previa is termed total. The placenta completely covers the internal cervical os.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time.

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

Disseminated Intravascular Coagulation (DIC) Define

*A serious bleeding & thrombotic disorder results from abnormally initiated & accelerated clotting *Blood clots form throughout the body blocking small blood vessels. *Characterized by the profuse bleeding that results from the depletion of platelets and clotting factors. *Always caused by underlying Dz or condition→ underlying problem must be tx for DIC to resolve *80% mortality rate

Abruptio Placentae (Placental Abruption) Define

*Complete or partial detachment of the placenta from uterus before delivery *Separation occurs in "decidua basalis" after 20 wks of gestation & before birth of infant. *Antepartum bleeding (1/3) d/t placental abruptio *Likely occurs in twin gestations ~Most devastating pregnancy complication ~Unpredictable & unpreventable ~Typically does not occur early pregnancy→ Seen in 2nd or 3rd trimester

Abruptio Placentae (Placental Abruption) Diagnostic tests

*Dx clinical of abruption: Confirm after birth by visual inspection of placenta. (Presence of Adherent clot of placenta & Depression of underlying placental surface) & when suspected (sudden uterine pain w or w/o vaginal bleeding) *Transabdominal ultrasound perform initially (followed by transvaginal scan -more accurate- only if can't locate) *Ultrasound -Rule out placenta previa (cannot detect all cases of abruption). -Retroplacental mass (detect w ultrasonographic exam... negative findings do not rule out life-threatening abruption) -Identifies 3 sources of abruption: between placenta and 1.Subchorionic (membranes) 2.Retroplacental (uterine wall) 3.Preplacental (amniotic fluid) (Retroplacental hematomas= assoc w worse fetal prognosis than is subchorionic hemorrhage)

Antihypertensive drugs Help prevent eclampsia (seizures)

*HYDRALIZINE "Apresoline, Neopresol" Arteriolar Vasodilator -For when systolic is greater > 160 -S/E: Palpitations, HA, decrease uteroplacental blood flow, increase HR/CO, oxygen consumption, N/V, Late deceleratioterm-251ns, low HR if mom's SBP +90 *LABETALOL "Normodyne, Trandate" Nonselective Beta Blockers ~Helps Decreases BP & HR -Causes vasodilation w/o significant change in CO -S/E: Bronchospasm, fatigue -Not if asthmatic or heart failure -Don't exceed 80 mg in single dose *NIFEDIPINE "Procardia, Adalat" Calcium Channel Blocker ~Vasodilation, Helps Decreases BP & HR -S/E: Peripheral edema, interfere w/ labor -No grape juice! Avoid w. magnesium sulfate (skeletal muscle blockade risk) -Not sublingual -Monitor BP & HR

HELLP Syndrome Treatment

*Most often definite treatment for HELLP: Delivery of baby *Hospitalization (bedrest & monitor closely until delivery) *Magnesium Sulfate: to treat/prevent seizures, not to decrease BP *Corticosteroids help mature fetal lungs *Blood transfusions really low platelet count *BP meds: hydralazine, labetalol, nifedipine *Monitor BP, urine output, CNA irritability, serum creatinine *Continuous EFM, BPP, U/S for fetal growth & amniotic fluid *Bedrest, side rails up, quiet environment *Emergency equipment at bedside *IV and oral fluids: not exceed 125 ml/hr (helps reduce risk of PE)

Eclampsia Definition

*Seizures or coma not attributable to other causes in a preeclamptic woman (Onset of seizure activity in a women w/ preeclampsia) ~No Hx of preexisting patho that causes seizures. -Risk: Tertiary referral centers, Multifetal gestation, No prenatal care ~Occur pre, intra, post birth (usually during antepartum period) -Regional anesthesia is NOT recommended for eclamptic women with coagulopathy or platelet count less than 50,000 -Eclampsia alone is not an indicated for immediate cesarean birth

Preeclampsia Risk Factors

-Hx (&/or family Hx) of preeclampsia in previous pregnancies -1st Pregnancy (Primigravida) -Obesity -Young <19 or Older >35 -African Descent -Medical Conditions (Chronic HTN, Renal Dz, DM, Autoimmune Dz: SLE) -Nulliparity -Multiple gestations "twins" -Smoking -Partner previous father other w/ preeclampsia

Magnesium Sulfate Toxicity

-Lethargy -Muscle weakness -Decreased DTRs (Level 0) -Double vision -Slurred speech -Low BP -Low HR -Low RR (<14 alert....< 12 BAD) -Low UO (<30 ml/hr) *IMPORTANT PARAMETER: DTR *Increase in toxicity indicated by → Decreased BP Bradycardia Decreased RR (< 14 is not good) Apnea Cardiac arrest **STOP magnesium infusion immediately **Calcium gluconate or calcium chloride (antidotes) can be given IV

HELLP Syndrome Manifestations

-Malaise -Flu-like sx -Epigastric/RUQ pain -HA (headache) -N/V (s/sx tend to worsen at night; improve during the day)

Magnesium Sulfate Interventions

-Restrict visitors -Maintain a dark quiet room during infusion -Limit fluid intake -Maintain quiet environment -Keep CA+ GLUCONATE *Check Magnesium levels: q 6 hours *Most important maternal hourly assessments of v/s assess hourly: Respiratory Rate (RR) *Magnesium is excreted via kidneys: Obtain urine output (indwelling catheter) (if renal function declines: not all of the magnesium can be excreted adequately... leads to mag toxicity) *Monitor sx of magnesium toxicity: CNS depression w hyporeflexia *If toxicity is suspected prompt action to prevent respiratory or cardiac arrest

Eclampsia Manifestations

-SEIZURESSSS -HA (headache) -Blurred vision -Severe epigastric pain -AMS (altered mental status)..coma *Can appear sudden without warning *Tonic contraction (arms flexed, fists clenched, legs inverted) tonic-clonic convulsion ■ Muscles alternatively relax & contract ■ Respirations halted & begin again w/ long, deep stertorous inhalations ■ Hypotension follows ■ Muscular twitching, disorientation, amnesia persist after convulsion ■ May also vomit or be incontinent of urine or stool

Kleihauer-Betke (KB) "not dx"

-To determine presence of fetal-to-maternal bleeding (transplacental hemorrhage). -May be useful to guide Rho(D) immunoglobulin therapy in Rh-negative women who have had an abruption

Which factor would cause a rise in temperature to 102°F (38.9°C) after a seizure in a client with eclampsia? a. Excessive muscular activity b. Development of a systemic infection c. Dehydration caused by rapid fluid loss d. Irregularity in the cerebral thermal center

AND: D Increased electrical charges in the brain during a seizure may disturb the cerebral thermoregulation center in the hypothalamus. Excessive muscular activity usually causes perspiration, leading to a drop in body temperature. One increased reading is not a conclusive sign of infection. Rapid fluid loss does not occur during a seizure; clients with preeclampsia have fluid retention.

A client, 38 weeks' gestation, has been diagnosed with HELLP syndrome. Which of the following changes is consistent with this diagnosis? a. Hematocrit dropped to 28%. b. Platelets increased to 300,000 cells/mm?. c. Red blood cells increased to 5.1 million cells/mm? d. Sodium dropped to 132 mEg/dL.

ANS: A

Which significant clinical finding would the nurse expect when reviewing the history of a client with preeclampsia? a. Proteinuria b. Tachycardia c. Increased serum glucose d. Tonic-clonic movements

ANS: A A characteristic of preeclampsia is vasospasms that cause renal injury, resulting in loss of protein in the urine. The maternal heart rate is not affected by preeclampsia. An increased serum glucose level is associated with uncontrolled diabetes, not preeclampsia. There are no data to indicate that the client had or is having a seizure. The admitting diagnosis is preeclampsia, not eclampsia.

A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? a. Altered glomerular filtration. b. Cardiac failure. c. Hepatic insufficiency. d. Altered splenic circulation.

ANS: A Altered glomerular filtration leads to protein loss and, subsequently, to fluid retention, which can lead to swelling in the face and hands. The hypertension associated with preeclampsia results in poor perfusion of the kidneys. When the kidneys are poorly perfused, the glomerlular filtration is altered, allowing large molecules, most notably the protein albumin, to be lost through the urine. With the loss of protein, the colloidal pressure drops in the vascular tree, allowing fluid to third space. The body gets the message to retain fluids, exacerbating the problem. One of the early signs of the third spacing is the swelling of a client's hands and face.

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time, she is at the greatest risk for: a. hemorrhage. b. infection. c. urinary retention. d. thrombophlebitis

ANS: A Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta.

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: a. hydralazine b. magnesium sulfate bolus. c. diazepam. d. calcium gluconate

ANS: A Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The patient is not currently displaying any signs or symptoms of magnesium toxicity.

Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? a. Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. b. Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. c. Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. d. Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion

ANS: A In the left-lateral position the gravid uterus no longer compresses major vessels; cardiac output is maintained; glomerular filtration and uterine perfusion rates increase. Maximizing intra-abdominal pressure on the iliac veins will decrease, not increase, blood flow to the pelvic area. Maximizing aortic compression will decrease, not increase, uterine blood flow. Hemoconcentration occurs and uterine perfusion decreases in the standing and sitting positions.

A patient with gestational hypertension is prescribed labetalol hydrochloride (Normodyne) therapy, which is continued after giving birth. What does the nurse instruct the patient about breastfeeding? a. "You may breastfeed the infant if you desire." b. "Breastfeeding may cause convulsions in the infant." c. "Breastfeed only once a day and use infant formulas." d. "There may be high levels of the drug in the breast milk."

ANS: A Labetalol hydrochloride (Normodyne) has a low concentration in breast milk, so the patient can breastfeed the infant. Breastfeeding is safe and will not cause convulsions or any side effects in the infant. Infant formulas are used only if the mother is unable to breastfeed the infant or if the mother does not desire to breastfeed.

Which condition is seen in a pregnant patient if uterine artery Doppler measurements in the second trimester of pregnancy are abnormal? a. Preeclampsia b. HELLP syndrome c. Molar pregnancy d. Gestational HTN

ANS: A Preeclampsia is a condition in which patients develop hypertension and proteinuria after 20 weeks' gestation. It can be diagnosed if uterine artery Doppler measurements in the second trimester of pregnancy are abnormal. HELLP syndrome is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP) in a patient with preeclampsia. Molar pregnancy refers to the growth of the placental trophoblast due to abnormal fertilization. Gestational hypertension is a condition in which hypertension develops in a patient after 20 weeks' gestation.

Which condition in a pregnant patient with severe preeclampsia is an indication for administering magnesium sulfate? a. Seizure activity b. Renal dysfunction c. Pulmonary edema d. Low blood pressure (BP)

ANS: A Severe preeclampsia may cause seizure activity or eclampsia in the patient, which is treated with magnesium sulfate. Magnesium sulfate is not administered for renal dysfunction and can cause magnesium toxicity in the patient. Pulmonary enema can be prevented by restricting the patient's fluid intake to 125 mL/hr. Increasing magnesium toxicity can cause low BP in the patient.

Which would the nurse implement to ensure the physical safety of a client with severe preeclampsia? a. Initiate seizure precautions b. Administer antihypertensive medication as ordered. c. Begin electronic fetal monitoring. d. Monitor strict intake and output

ANS: A This client may become eclamptic suddenly and have a seizure; seizure precautions are necessary to keep her from injuring herself and the fetus. All answer options are appropriate interventions for a pre-eclamptic patient. However, seizure precautions are implemented for physical safety.

Which is the priority nursing action when a client admitted with preeclampsia has a seizure? a. Turning the client's head to the side b. Checking the client for an imminent birth c. Inserting an airway into the client's mouth d. Checking for bleeding from the client's vagina

ANS: A Turning the client's head to the side will allow saliva to drain front the mouth by gravity, which will help maintain a patent airway. Although birth may be imminent, the priority is maintaining a patent airway. Placing an airway in the client's mouth is contraindicated because it may cause injury. Inspecting the client's vagina is not the priority, and bleeding is not an expected response to a seizure.

Intravenous magnesium sulfate therapy is instituted for a client with severe preeclampsia who has a blood pressure of 170/110 mm Hg, a pulse of 108 beats/min, and a respiratory rate of 24 breaths/min. Eight hours later her blood pressure is 150/110 mm Hg, the pulse is 98 beats/min, the respiratory rate is 10 breaths/min, and the knee-jerk reflex is absent. Which action would the nurse take in response to these findings? a. Stop the infusion of magnesium sulfate and notify the primary health care provider. b. Administer calcium gluconate, because it is an antidote to magnesium sulfate. c. Continue the magnesium sulfate infusion, because the blood pressure is still high. d. Check vital signs and reflexes in 1 hour and then discontinue the infusion if necessary.

ANS: A Near-toxic levels of magnesium sulfate are suggested by the disappearance of the knee-jerk reflex and by depressed respirations (fewer than 12 breaths/min). This is a life-threatening situation, and the infusion must be stopped, and the primary health care provider notified immediately. Calcium gluconate may be given as an antidote, but the infusion of magnesium sulfate must be stopped first. Magnesium sulfate is not antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.

In planning care for women with preeclampsia, nurses should be aware that: a. Induction of labor is likely, as near term as possible. b. If at home, the woman should be confined to her bed, even with mild preeclampsia. c. A special diet low in protein and salt should be initiated. d. Vaginal birth is still an option, even in severe cases.

ANS: A Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

Which conditions during pregnancy can result in preeclampsia in the patient? Select all that apply. a. Genetic abnormalities b. Dietary deficiencies c. Abnormal trophoblast invasion d. Cardiovascular changes e. Maternal hypotension:

ANS: A, B, C, D Current theories consider that genetic abnormalities and dietary deficiencies can result in preeclampsia. Abnormal trophoblast invasion causes fetal hypoxia and results in maternal hypertension. Cardiovascular changes stimulate the inflammatory system and result in preeclampsia in the pregnant patient. Maternal hypertension, and not hypotension, after 20 weeks' gestation is known as preeclampsia.

Which hypertensive disorders can occur during pregnancy? Select all that apply a. Chronic Hypertension b. Preeclampsia-eclampsia c. Hyperemesis gravidarum d. Gestational Hypertension e. Gestational trophoblastic disease

ANS: A, B, D Chronic hypertension refers to hypertension that developed in the pregnant patient before 20 weeks' gestation. Preeclampsia refers to hypertension and proteinuria that develops after 20 weeks' gestation. Eclampsia is the onset of seizure activity in a pregnant patient with preeclampsia. Gestational hypertension is the onset of hypertension after 20 weeks' gestation. Gestational trophoblastic disease and hyperemesis gravidarum are not hypertensive disorders. Gestational trophoblastic disease refers to a disorder without a viable fetus that is caused by abnormal fertilization. Hyperemesis gravidarum is excessive vomiting during pregnancy that may result in weight loss and electrolyte imbalance.

What does the nurse assess to detect the presence of a hypertensive disorder in a pregnant patient? Select all that apply. a. Proteinuria b. Epigastric pain c. Placenta previa d. Presence of edema e. Blood pressure (BP):

ANS: A, B, D, E Proteinuria indicates hypertension in a pregnant patient. Proteinuria is concentration e300 mg/24 hours in a 24-hour urine collection. The nurse needs to assess the patient for epigastric pain because it indicates severe preeclampsia. Hypertension is likely to cause edema or swollen ankles as a result of greater hydrostatic pressure in the lower parts of the body. Therefore the nurse needs to assess the patient for the presence of edema. Accurate measurement of BP will help detect the presence of any hypertensive disorder. A systolic BP greater than 140 mm Hg or a diastolic BP greater than 90 mm Hg will indicate hypertension. Placenta previa is a condition wherein the placenta is implanted in the lower uterine segment covering the cervix, which causes bleeding when the cervix dilates.

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms should the nurse expect to observe? Select all that apply. a. Decreased urinary output and irritability. b. Transient headache and +1 proteinuria c. Ankle clonus and epigastric pain d. Platelet count of less than 100,000/mm3 and visual problems e. Seizure activity and hypotension

ANS: A, C, D Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.

Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply! a. Monitoring deep tendon reflexes b. Assessing urine output every 8 hours. c. Maintaining a dark, quiet environment d. Using a pump to regulate the medication. e. Having calcium gluconate available at the bedside. f. Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min:

ANS: A, C, D, E Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider.

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. a. Headache b. Constipation c. Abdominal pain d. Vaginal bleeding e. Flulike symptoms

ANS: A, C, E Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia

A client with mild preeclampsia is admitted to the labor and birthing suite. Which signs or symptoms would the client be likely to display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. a. Headache b. Constipation c. Right upper quadrant abdominal pain d. Vaginal bleeding e. Nausea and vomiting

ANS: A, C, E Headache, right upper quadrant abdominal pain, and nausea and vomiting are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. a. Headache b. Constipation c. Abdominal Pain d. Vaginal bleeding e. Visual disturbances.

ANS: A, C, E Headache in severe preeclampsia is related to cerebral edema. Abdominal pain in severe preeclampsia is related to decreased circulating blood volume and generalized edema. Visual disturbances in severe preeclampsia are related to retinal edema. Constipation and vaginal bleeding are not related to preeclampsia.

Which orders are appropriate for a client with mild preeclampsia? Select all that apply. a. Daily weight b. Side-lying bed rest c. 2 g/day sodium diet d. Monitor deep tendon reflexes e. Glucose tolerance test

ANS: A, D Rapid weight gain is a sign of increasing edema. One liter of fluid is equal to 2.2 lb. Maintaining bed rest is no longer recommended for patients with mild preeclampsia. Sodium restriction is not recommended for preeclamptic clients. Deep tendon reflexes should be monitored. Reflexes of +2 are indicative of mild preeclampsia; +4 indicates severe preeclampsia. There are no data indicating that a glucose tolerance test is needed.

A nurse is observing a patient with severe preeclampsia when the patient begins to have a seizure. The nurse calls for help. Which of the following is the most critical intervention for the nurse to perform next? a. Raise side rails and pad them b. Lower the head of the bed and turn the woman's head to one side c. Record the time, length, and type of seizure activity d. Administer magnesium sulfate per orders

ANS: B

The nurse observes that a pregnant patient with gestational hypertension who is on magnesium sulfate therapy is prescribed nifedipine (Adalat). What action does the nurse take? a. Evaluates the patient's renal function test. b. Obtains a prescription for a change of drug. c. Reduces the nifedipine (Adalat) dose by 50% d. Administers both medications simultaneously.

ANS: B Concurrent use of nifedipine (Adalat) and magnesium sulfate can result in skeletal muscle blockade in the patient. Therefore the nurse needs to report immediately to the primary health care provider (PHP) and obtain a prescription for a change of drug. The nurse assesses the patient's renal function to determine the risk for toxicity after administering any drug. However, it is not a priority in this case. Reducing the nifedipine (Adalat) dose is not likely to prevent the drug interaction in the patient. The nurse does not administer both drugs simultaneously because it may be harmful for the patient.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

Which lab result would the nurse expect in the client diagnosed with DIC? a. A decreased prothrombin time (PT) b. A low fibrinogen level c. An increased platelet count d. An increased white blood cell count

ANS: B Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion. ANS:

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient's health history places her at risk for abruptio placentae? a. childhood polio b. preeclampsia c.. c-section d. her age:

ANS: B Preeclampisa is a risk factor for experiencing abruptio placentae. The patient is at risk for developing this condition again since she is currently experiencing uncontrolled hypertension with this pregnancy.

Which nursing intervention is the most effective in preventing a seizure in a client with severe preeclampsia? a. Providing a plastic airway b. Controlling external stimuli c. Having emergency equipment available d. Keeping calcium gluconate at the bedside

ANS: B Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizure. A plastic airway will not prevent a seizure. Available emergency equipment will not prevent a seizure, although oxygen and suction equipment may be useful after a seizure. Calcium gluconate is the antidote for magnesium sulfate toxicity; it does not prevent seizures.

A pregnant patient has a systolic blood pressure that exceeds 160 mm Hg. Which action should the nurse take for this patient? a. Administer magnesium sulfate intravenously. b. Obtain a prescription for antihypertensive medications. c. Restrict intravenous and oral fluids to 125 mL/hr. d. Monitor fetal heart rate (FHR) and uterine contractions (UCs).

ANS: B Systolic blood pressure exceeding 160 mm Hg indicates severe hypertension in the patient. The nurse should alert the health care provider and obtain a prescription for antihypertensive medications, such as nifedipine (Adalat) and labetalol hydrochloride (Normodyne). Magnesium sulfate would be administered if the patient was experiencing eclamptic seizures. Oral and intravenous fluids are restricted when the patient is at risk for pulmonary edema. Monitoring FHR and UCs is a priority when the patient experiences a trauma so that any complications can be addressed immediately.

A patient who is 25 weeks pregnant has partial placenta previa. As the nurse you're educating the patient about the condition and self-care. Which statement by the patient requires you to re-educate the patient? a. "I will avoid sexual intercourse and douching throughout the rest of the pregnancy." b. "I may start to experience dark red bleeding with pain." c. "I will have another ultrasound at 32 weeks to re-assess the placenta's location." d. "My uterus should be soft and non-tender."

ANS: B The answer is B. All the other options are CORRECT about partial placenta previa. Option B is WRONG because this condition will present with PAINLESS, bright red bleeding NOT with pain and dark red bleeding, which happens in abruptio placentae.

A 39-year-old at 37 weeks' gestation admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hours earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? a. Placenta previa b. Abruptio placentae c. Ectopic pregnancy d. Spontaneous abortion

ANS: B The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae.

An intravenous infusion of magnesium sulfate is prescribed for a client with severe preeclampsia. The dosage is twice the usual adult dosage. When a nurse questions the dosage, the primary healthcare provider insists that it is the desired dosage and directs the nurse to administer the medication. How should the nurse respond to this directive? a. Administer the dose and monitor the client. b. Withhold the dose and notify the nurse manager. c. Administer the dose and document it on the client's record. d. Withhold the dose and notify the director of the obstetric department

ANS: B To administer the incorrect dose would be an act of negligence that could endanger the client, and the nurse would be liable. If the dosage is not changed after the primary healthcare provider is questioned, the nurse should contact the nurse manager. The medication should be withheld, because it could cause respiratory depression and endanger both the client and fetus. The nurse should follow hospital protocol and notify the nurse manager, not the director of the obstetrics department, first.

Which cytokine stimulates the liver to produce fibrinogen and protein C? a. Interleukin-1 b. Interleukin-6 c. Thrombopoietin d. Tumor necrosis factor

ANS: B Interleukin-6 stimulates the liver to produce fibrinogen and protein C. Interleukin-1 stimulates the production of prostaglandins. Thrombopoietin increases the growth and differentiation of platelets. Tumor necrosis factor stimulates delayed hypersensitivity reactions and allergies.

Which is the priority nursing care for a client at 38 weeks' gestation, admitted with the diagnosis of placenta previa? a. Withholding oral intake b. Assessing for hemorrhage c. Avoiding extraneous stimuli d. Encouraging supervised ambulation.

ANS: B To help prevent maternal and fetal complications, the client must be continuously monitored for blood loss through inspections for external bleeding and counting and weighing of perineal pads. Withholding oral intake is not appropriate at this time but may become necessary if bleeding is continuous and profuse and a cesarean birth is imminent. There is no indication that the client has preeclampsia or that cerebral irritation is present, so avoidance of stimuli is not necessary in this scenario. As a means of minimizing further placental separation the client is kept on bed rest.

The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits: a. a sleepy, sedated affect. b. a respiratory rate of 10 breaths/min. c. deep tendon reflexes of 2. d. absent ankle clonus.

ANS: B A respiratory rate of 10 breaths/min indicates that the patient is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the patient will most likely become sedated when the infusion is initiated. Deep tendon reflexes of two and absent ankle clonus are normal findings.

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH).

ANS: B All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of: a. anxiety due to hospitalization. b. worsening disease and impending convulsion. c. effects of magnesium sulfate. d. gastrointestinal upset.

ANS: B 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. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should a. apply heat to the knee. b. immobilize the knee joint. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? a. Amniocentesis for fetal lung maturity b. Ultrasound for placental location c. Contraction stress test (CST) d. Internal fetal monitoring

ANS: B The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

.A pregnant patient with severe preeclampsia who is being transported to a tertiary care center needs to be administered magnesium sulfate injection for seizure activity. What actions does the nurse take when administering the drug? Select all that apply. a. A 10-g dose is administered in the buttock. b. A local anesthetic is added to the solution. c. The Z-track technique is used to inject the drug. d. The injection site is massaged after the injection. e. The subcutaneous route is used to inject the drug

ANS: B, C, D The nurse adds a local anesthetic to the solution to reduce pain that is caused by the injection. The Z-track technique is used to inject the drug so that the drug is injected in the intramuscular (IM) tissue safely. The nurse gently massages the site after administering the injection to reduce pain. The nurse administers two separate injections of 5 g in each buttock. Magnesium sulfate injections are administered in the IM layer and not the subcutaneous layer.

What does the nurse include in the plan of care of a pregnant patient with mild preeclampsia? Select all that apply. a. Ensure prolonged bed rest. b. Provide diversionary activities. c. Encourage the intake of more fluids. d. Restrict sodium and zinc in the diet. e. Refer to Internet-based support group.

ANS: B, C, E Activity is restricted in patients with preeclampsia, so it is necessary to provide diversionary activities to such patients to prevent boredom. The nurse encourages the patient to increase fluid intake to enhance renal perfusion and bowel function. The nurse can suggest Internet-based support groups to reduce boredom and stress in the patient. Patients need to restrict activity, but complete bed rest is not advised because it may cause cardiovascular deconditioning, muscle atrophy, and psychological stress. The patient needs to include adequate zinc and sodium in the diet for proper fetal development.

A woman who is admitted to labor and delivery with preeclampsia at 30 weeks' gestation is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? a. Temperature b. Pulse c. Respiratory rate d. Blood pressure

ANS: C

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The patient complains, "I'm so thirsty and warm." The nurse: a. calls for a stat magnesium sulfate level. b. administers oxygen. c. discontinues the magnesium sulfate infusion. d. prepares to administer hydralazine.

ANS: C The patient is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.

. A nurse is teaching a client with preeclampsia regarding methods for improving her health. What is the most therapeutic instruction for the nurse to provide this client? a. "Eat a sodium-restricted diet." b. "Walk at least 1 mile (2.2 km) every day." c. "Rest often in the side-lying position." d. "Limit fluid intake to 1000 mL daily."

ANS: C Rest is advised to reduce arteriolar spasm, and the side-lying position promotes more efficient venous return to the heart; this improves cardiac output and placental perfusion. Sodium is necessary to maintain circulatory volume and should not be restricted in the diet. Excessive walking is contraindicated; too much walking may increase general arteriolar spasm. Fluid restriction is contraindicated, and, because of the increased circulatory volume during pregnancy, the client needs 2000 mL of fluid per day.

A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks' gestation. She's at risk of which of the following blood dyscrasias? a. Thrombocytopenia b. Idiopathic thrombocytopenic purpura (ITP) c. Disseminated intravascular coagulation (DIC) d. Heparin-associated thrombosis and thrombocytopenia (HATT)

ANS: C Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage. Option A (Thrombocytopenia) results from decreased production of platelets. Option D: a patient with abruptio placentae wouldn't get heparin and as a result, wouldn't be at risk for HATT.

A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this finding: a. This is known as marginal placenta previas. b. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another ultrasound at about 32 weeks' gestation. c. The patient will need to have a c-section and cannot deliver vaginally. d. The woman should report any bleeding immediately to the doctor.

ANS: C All the other options are CORRECT. Option C is FALSE. This is a type of placenta previa called marginal (or low-lying). There is a chance the woman can delivery vaginally, but if the placenta was completely over the cervix or partially covering it a c-section would be required. At the 20 week ultrasound the location of the placenta is detected. The location will be re-evaluated at about 32 weeks. If a placenta is found to be low lying there is a chance the placenta will move upward (away from the cervix) as the uterus grows to accommodate the baby.

A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? a. "Bed rest will help you to conserve energy for your labor." b. "Bed rest will help to relieve your nausea and anorexia." c. "Reclining will increase the amount of oxygen that your baby gets." d. "The position change will prevent the placenta from separating."

ANS: C Bed rest, especially side-lying, helps to improve perfusion to the placenta. This question requires the nurse to have a clear understanding of the pathology of preeclampsia. Only with an understanding of the underlying disease, can the test taker be able to remember the rationale for many aspects of client care. The vital organs of preeclamptic 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.

Which of these clinical manifestations would the nurse report to the healthcare provider immediately in a client with preeclampsia? a. Audible crackles in the lower lung fields b. Weight gain of 5 pounds in 2 weeks c. Severe headache d. Generalized facial edema

ANS: C Blurred vision, epigastric pain, and severe headache are all signs of preeclampsia and are ominous. If treatment is not provided, eclampsia may follow. Although generalized facial edema and weight gain are indications of worsening preeclampsia, they are not ominous as severe headaches. Audible crackles may indicate pulmonary edema in the preeclamptic patient.

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the womans latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of: a. Eclampsia. b. Disseminated intravascular coagulation (DIC). c. HELLP syndrome. d. Idiopathic thrombocytopenia.

ANS: C HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.

Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles

ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions are also appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid other venipunctures. b. Apply dressings to the sites. c. Notify the health care provider. d. Give prescribed proton-pump inhibitors.:

ANS: C The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions are also appropriate, but the most important action should be to notify the health care provider so that DIC treatment can be initiated rapidly.

After a client gives birth she has the following vital signs: temperature 99.4°F (37.4°C); pulse rate 80 beats/min and regular; respiratory rate of 16 breaths/min, with even respirations; and blood pressure of 148/92 mm Hg. Which vital sign would the nurse continue to monitor closely? a. Pulse rate b. Temperature c. Blood pressure d. Respiratory rate

ANS: C This client's blood pressure is high. Gestational hypertension and preeclampsia may occur during the early postpartum period, and the blood pressure should be monitored. If it returns to a healthy level within 12 weeks, it is called transient hypertension. The pulse rate is within expected limits. A temperature of 99.4°F (37.4°C) is a normal physiological response after labor, the result of exertion, stress, and mild dehydration. The respiratory rate is within expected limits.

Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors? a. A 30-year-old obese Caucasian with her third pregnancy b. A 41-year-old Caucasian primigravida c. An African-American client who is 19 years old and pregnant with twins d. A 25-year-old Asian-American whose pregnancy is the result of donor insemination.

ANS: C Three risk factors are present for this woman. She is of African American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy.

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. Which is the nurse's most important goal for the client at this time? a. Easing her anxiety b. Limiting the bleeding c. Reducing her blood pressure d. Decreasing the circulating blood volume

ANS: C Treatment is directed primarily toward reducing the blood pressure and preventing seizures. Although anxiety may be present, easing it is not the priority. Bleeding is not generally a problem with preeclampsia unless abruptio placenta occurs. With preeclampsia there is already a decrease in circulating blood volume, which causes hemoconcentration and decreased organ perfusion.

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which assessment finding would prompt the nurse to withhold the medication and notify the primary health care provider? a. Urine output of 30 mL/h b. Respirations of 14 breaths/min c. Absence of deep tendon reflexes d. Blood pressure of 140/100 mm Hg

ANS: C A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. The amount of urine output is important, because oliguria gay signify magnesium toxicity, but 30 mL/h is within the acceptable range. A respiratory rate of 14 breaths/min is a positive sign that toxicity has not occurred. A respiratory rate of 12 breaths/min or slower is a concern that requires nursing intervention. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.

What instruction does the nurse provide to a pregnant patient with mild preeclampsia? a. "You need to be hospitalized for fetal evaluation." b. "Nonstress testing can be done once every month." c. "Fetal movement counts need to be evaluated daily." d. "Take complete bed rest during the entire pregnancy."

ANS: C Preeclampsia can affect the fetus and may cause fetal growth restrictions, decreased amniotic fluid volume, abnormal fetal oxygenation, low birth weight, and preterm birth. Therefore the fetal movements need to be evaluated daily. Patients with mild preeclampsia can be managed at home effectively and need not be hospitalized. Nonstress testing is performed once or twice per week to determine fetal well-being. Patients need to restrict activity, but complete bed rest is not advised because it may cause cardiovascular deconditioning, muscle atrophy, and psychological stress.

Which intervention will help prevent the risk of pulmonary edema in a pregnant patient with severe preeclampsia? a. Assess fetal heart rate (FHR) abnormalities regularly. b. Place the patient on bed rest in a darkened environment. c. Restrict total intravenous (I.V.) and oral fluids to 125 mL/hr. d. Ensure that magnesium sulfate is administered as prescribed.

ANS: C Pulmonary edema may be seen in patients with severe preeclampsia. Therefore the nurse needs to restrict total intravenous (I.V.) and oral fluids to 125 mL/hr. FHR monitoring helps assess any fetal complications. The patient is placed on bed rest in a darkened environment to prevent stress. Magnesium sulfate is administered to prevent eclamptic seizures.

Magnesium sulfate is given to women with preeclampsia and eclampsia to: a. Improve patellar reflexes and increase respiratory efficiency. b. Shorten the duration of labor. c. Prevent and treat convulsions. d. Prevent a boggy uterus and lessen lochial flow.

ANS: C Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy

Nurses should be aware that HELLP syndrome: a. is a mild form of preeclampsia. b. can be diagnosed by a nurse alert to its symptoms. c. is characterized by hemolysis, elevated liver enzymes, and low platelets. d. is associated with preterm labor but not perinatal mortality.

ANS: C The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased, and so is perinatal mortality

The nurse is caring for a client receiving magnesium sulfate for treatment of preeclampsia. Which finding alerts the nurse to signs of magnesium sulfate toxicity? SATA: a. Proteinuria b. Epigastric Pain c. Loss of patellar reflexes d. Urine output of 40 mL/h e. Respirations of 10 breaths/min

ANS: C, E. c. Loss of patellar reflexes e. Respirations of 10 breaths/min A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/h is an acceptable output; an output of less than 30 mL/h may contribute to the development of a toxic level of magnesium.

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse? a. Blood pressure (BP) increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day

ANS: C. A dipstick value of 3+ for protein in her urine Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally, HTN is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or in diastolic pressure of 15 mm Hg. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore, presence of edema is no longer considered diagnostic of preeclampsia.

The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? a. The patient with placenta previa b. The patient whose vagina is colonized with group B streptococcal c. The patient who is hepatitis B surface antigen positive d. The patient with eclampsia

ANS: D

A 36-year-old primigravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, which nursing intervention is of the highest importance at this time? a. Assessing the fetal heart rate for tachycardia b. Promoting adequate urine output by offering oral fluids. c. Monitoring respiratory status and ascertaining that calcium gluconate is at the bedside. d. Notifying the primary healthcare provider regarding the epigastric pain, headache, and blurred vision.

ANS: D Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours would be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible. Because the client is receiving a central nervous system depressant, it is more likely that the fetal heart rate will be decreased. The client is usually on nothing-by-mouth status during magnesium sulfate administration, particularly with unstable clinical findings, because of the possible need for an emergency cesarean birth. Although it is important to monitor the client's respirations and to ensure that calcium gluconate (magnesium sulfate antagonist) is available, neither is the priority in a life-threatening situation.

A client was prescribed a medication for preeclampsia and later developed muscle weakness, edema, and nausea. Which medication was administered to the client? a. Nifedipine b. Terbutaline c. Indomethacin d. Magnesium sulfate

ANS: D Magnesium sulfate can be administered for preeclampsia; this medication may cause magnesium toxicity. Adverse effects of magnesium sulfate include muscle weakness, edema, and nausea. Calcium gluconate is administered to treat magnesium toxicity. Nifedipine, an antihypertensive agent, formerly listed as a category C medication, and can be safely used to treat gestational hypertension. Terbutaline is a beta- adrenergic blocker used to manage preterm labor. Indomethacin is a nonsteroidal anti-inflammatory medication used as a tocolytic for the management of preterm labor.

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

ANS: D 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 client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. Which condition would the nurse anticipate when assessing this infant? a. Prematurity b. Cardiac anomalies c. Respiratory infection d. Intrauterine growth restriction

ANS: D The pathological changes of maternal chronic vascular disease cause uteroplacental insufficiency; vasospasms diminish fetal oxygenation and nutrition, which lead to slow fetal growth. Prematurity is defined as gestational age of less than 37 weeks. There is no greater incidence of cardiac anomalies in infants with-intrauterine growth restriction. Neither is there a greater incidence of infection in infants with low birth weight; however, they may have a lower resistance to infection.

Which is a priority nursing action when a pregnant patient with severe gestational hypertension is admitted to the health care facility? a. Prepare the patient for cesarean delivery. b. Administer intravenous (I.V.) and oral fluids. c. Provide diversionary activities during bed rest. d. Administer the prescribed magnesium sulfate.

ANS: D The nurse administers the prescribed magnesium sulfate to the patient to prevent eclamptic seizures. I.V. oral fluids are indicated when there is severe dehydration in the patient. It is important to provide diversionary activities during bed rest, but it is secondary in this case. A patient who has experienced a multisystem trauma is prepared for cesarean delivery if there is no evidence of a maternal pulse, which increases the chance of maternal survival

Nurses should be aware that chronic hypertension is: a. Defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy. b. Considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg. c. General hypertension plus proteinuria. d. Can occur independently of or simultaneously with gestational hypertension.

ANS: D Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks after birth. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to: a. inserts an oral airway. b. suction the mouth to prevent aspiration. c. administer oxygen by mask. d. stay with the patient and call for help.

ANS: D If a patient becomes eclamptic, the nurse should stay her and call for help. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the patient's mouth. Oxygen would be administered after the convulsion has ended.

A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: a. eclamptic seizure. b. rupture of the uterus. c. placenta previa. d. placental abruption.

ANS: D Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal? a. The client's clot formations will resolve in two days. b. The saturation of the client's dressings will be documented. c. The client will use lemon-glycerin swabs for oral care. d. The client's urine output will be > 30 mL per hour.

ANS: D. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL/hr indicates the kidneys are being adequately perfused and the body is not in shock.

Which action would the nurse take based on receiving a laboratory report stating that a client receiving magnesium sulfate 2 g/h IV for preeclampsia has a magnesium level of 6.4 mEq/L (0.30 mmol/L)? a. Stop the infusion. b. Assess the client's deep tendon reflexes. c. Assess the client's level of consciousness. d. Document the level on the fetal monitoring strip.

ANS:D Documentation of the magnesium level on the fetal monitoring strip can serve as a point of correlation between the blood level and a decrease in fetal activity or fetal heart rate reactivity, which is common in a client receiving magnesium sulfate. There is no indication that the infusion of magnesium sulfate needs to be stopped. The therapeutic range for magnesium for the preeclamptic client is 4 to 7 mEg/L (0.28-0.44 mmol/L). The client's level is within the therapeutic range, so assessing for signs of magnesium toxicity is not an action based on this lab result.

Abruptio Placentae (Placental Abruption) Lab Findings

APT test: -Positive (blood in amniotic fluid) Hgb (Hemoglobin) & Hct (Hematocrit): -Decreases (may appear later) Coagulation Factors: -Decreased -Clotting defects (DIC may be present) *Most abruptions are no accompanied by maternal coagulopathy (unless large) FHR: -Normal (elevated if major detachments of placenta occurs) Fundal height -measure over time (Increasing= concealed bleeding). -Often greater than expected for gestational age d/t fetal malpresentation: (breech & transverse or oblique lie) UO (urine Output): -Decrease -Best indicator of acute blood loss *HgB & Fibrinogen tests are done to rule out DIC

HYDRALIZINE "Apresoline, Neopresol"

Arteriolar Vasodilator *For when systolic is greater > 160 *Mom S/E: Palpitations, HA, decrease uteroplacental blood flow, increase HR/CO, oxygen consumption, N/V *Fetus S/E: Tachycardia, Late deceleratioterm-251ns, low HR if mom's SBP +90 ➔ Assess for effects of medication ➔ Teach expected effects of medication ➔ Assess BP frequent (Sudden drop can lead to shock/placental abruption ➔ Multiple doses? wait 20 mins after 1st dose to give additional dose (allow time to assess effects of the initial dose ➔ Assess urinary output ➔ Bed rest lateral position/side rails up ➔ Caution in maternal tachycardia

Disseminated Intravascular Coagulation (DIC) PATHOLOGY

Causative factor (underlying disease) ↓ Inflammatory response causes inflammation & coagulation in the vasculature ↓ The fibrinolytic system is halted ↓ Causes lots of small clots & platelets to clump ↓ TOO LITTLE CLOTTING: -Lots of small clots are using all the blood's clotting factors. This leaves other parts of the body with no means of stopping any bleeding. & TOO MUCH CLOTTING: -Excessive clotting causes blockage of blood vessel which can lead to organ ischemia (because organs are not getting blood supply).

Disseminated Intravascular Coagulation (DIC) Lab findings (SPECIAL TEST)

D-Dimer: INCREASED (>0.50) FSPs (norm <10): INCREASED (>11) Factor Assays "prothrombin & factors V, VIII, X, XIII": DECREASED AT III: DECREASED Protein C & S: DECREASED Plasminogen "TPA": DECREASED Peripheral Red Blood Smear: PRESENT SCHISTOCYTES Soluble Fibrin Monomer: POSITIVE

Disseminated Intravascular Coagulation (DIC) THROMBOSIS Manifestations

INTEGUMENTARY: -Cyanosis -Ischemic tissue Necrosis (ex/ Gangrene) -Hemorrhagic necrosis RESPIRATORY: -Tachypnea -Dyspnea -Pulmonary emboli -ARDS CARDIOVASUCULAR: -Electrocardiogram (ECG) changes -Venous distention GI: -Abdominal pain -Paralytic ileus URINARY: -Kidney damage & failure -Oliguria Stroke, Heart Attack, DVT or PE.

Disseminated Intravascular Coagulation (DIC) BLEEDING Manifestations

INTEGUMENTARY: -Pallor -Petechiae -Purpura -Oozing blood -Venipuncture site bleeding -Hematomas -Occult hemorrhage RESPIRATORY: -Tachypnea -Hemoptysis -Orthopnea CARDIOVASUCULAR: -Hypotension GI: -Upper & lower GI bleeding -Abdominal distention -Bloody tarry stools (Melena) URINARY: -Hematuria NEURO: -Vision changes -Dizziness -Headache -Changes in mental status -Irritability MUSCULOSKELETAL: -Bone & joint pain

HELLP Syndrome Definition

Lab Dx for a variety of severe preeclampsia; involves hepatic dysfunction, characterized by: ➔ Hemolysis (H) ➔ Elevated Liver enzymes (EL) ➔ Low Platelet count (LP) *Rapid develop *Usually in antepartum period *Form of severe preeclampsia (or not) *Proteinuria: may be absent *Preterm birth: high *Most perineal deaths: Before 28 wks assoc w/ placental abruption or severe fetal growth

Abruptio Placentae (Placental Abruption) Manifestations

PAIN (Mild to severe) -Abdominal pain (feels hard "boardlike") -Localized over 1 region of uterus OR over uterus w board like abdomen VAGINAL BLEEDING -Dark red: higher up in the uterus -Extensive myometrial bleeding: (damages uterine muscle) -Couvelaire Uterus -Coagulopathy Uterine hypertonicity (mild-severe) Uterine tenderness & contractions -NO palpable relaxation between contractions *Board like abdomen -Uterus tense/rigid/hard/board like/no bleeding (aka Couvelaire uterus)

Abruptio Placentae (Placental Abruption) Medications

Tocolysis *Controversial in tx for placental abruption Only good if: -Hemodynamically stable -No evidence of fetal jeopardy exists -If preterm fetus benefits from corticosteroids or delay of delivery Tocolytics: Nifedipine (Adalat, Procardia, Nifediac CC, Nifedical XL) *Allow for effective administration of glucocorticoids to preterm fetus to accelerate fetal lung maturation *Chronic abruption: help delay delivery to gestational age when prematurity complications less severe *Also work by blocking influx of Ca+ into uterine muscle cells, decreasing contractions, which are dependent on Ca+ Magnesium sulfate

Disseminated Intravascular Coagulation (DIC) Medications.

Vasopressors: -Vasoconstriction which increases blood flow & increases perfusion to organs. Heparin infusion Anticoagulant agents -Stops clotting which increases blood flow to organs. LMWH Cryoprecipitate: -Replaces fibrinogen, factors V & VII -Give when fibrinogen levels are < 100 Antiplatelet agents "Aspirin, Clopidogrel" Thrombin inhibitors Thrombolytic agents "Streptokinase, Alteplase, end- teplase"

Disseminated Intravascular Coagulation (DIC): Possible Findings in women's examination

~Spontaneous bleeding in gums or nose ~Petechiae from BP cuff ~Excessive bleeding from trauma site (even a slight trauma such as a venipuncture) ~Hypotension that is out of proportion to observed blood loss. ~Tachycardia ~Diaphoresis