Reproduction Sem 4
A pregnant client is admitted to the high-risk unit with uterine tenderness and some dark-red vaginal bleeding. Abruptio placentae is diagnosed. Which priority assessment should be included with vital signs, skin color, urine output, and fetal heart rate? 1 Fundal height 2 Obstetric history 3 Time of last meal 4 History of bleeding tendencies
1, Fundal height It is vital that a baseline measurement be obtained, because increasing fundal height may be a sign of concealed hemorrhage. Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments; however, none are a priority at this critical time.
The nurse is performing a physical assessment of a pregnant woman. Which factor in the client's history increases the risk for abruptio placentae? 1 Hydramnios 2 Hypertension 3 Cardiac disease 4 Diabetes mellitus
2, Hypertension Abruptio placentae occurs in about 1% of all pregnancies. The problem is more common in women with hypertension; however the causative factors are not clear. Hydramnios occurs about 10 times more often in pregnancies involving clients with type 1 diabetes. Spontaneous abortion, preterm labor and birth, and intrauterine fetal growth retardation are more common in pregnant clients with heart disease than in those without it. There is not a higher incidence of abruptio placentae in clients with diabetes mellitus; clients with diabetes are more likely to experience preeclampsia or to go into preterm labor if they have diabetes before becoming pregnant, especially if pathologic changes related to diabetes are present.
Which clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding
3, Boardlike abdomen Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.
The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history? 1 Cardiac disease 2 Hyperthyroidism 3 Gestational hypertension 4 Cephalopelvic disproportion
3, Gestational hypertension Hypertension during pregnancy leads to vasospasm; this in turn causes the placenta to tear away from the uterine wall (abruptio placentae). Generally cardiac disease does not cause abruptio placentae. Hyperthyroidism may cause an endocrine disturbance in the infant but does not affect blood supply to the uterus. Cephalopelvic disproportion may affect the birth of the fetus but does not affect the placenta.
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. 1 Headache 2 Constipation 3 Abdominal pain 4 Vaginal bleeding 5 Flulike symptoms
ANS: 1, 3, 5 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 nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death
D. Gravida I who has had an intrauterine fetal death 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.
A client with abruptio placentae has an emergency cesarean birth. Subsequently the nurse notes bloody urine in the indwelling catheter collection bag. Which impending problem does the nurse suspect? 1 Incisional nick in the bladder 2 Urinary infection from the catheter 3 Uterine relaxation with increased lochia 4 Disseminated intravascular coagulopathy
1, Incisional nick in the bladder During an emergency cesarean birth the urinary bladder may be nicked during attempts to reach the uterus. Bleeding associated with a urinary tract infection is unlikely to develop so soon after a birth. Lochia is expelled from the vagina, not the bladder. With dissociated intravascular coagulopathy there would be bleeding from other sites, such as the incision and the venipuncture site, not just the bladder.
The nurse knows that when a magnesium sulfate infusion is given to a client with preeclampsia, it can build to a toxic level. Which assessment finding should prompt the nurse to withhold the medication and notify the primary healthcare provider? 1 Respirations of 14 breaths/min 2 Absence of deep tendon reflexes 3 Urine output of 30 mL/hr 4 Blood pressure of 140/100 mm Hg
2 Absence of deep tendon reflexes A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. Respirations 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 amount of urine output is important, because oliguria may signify magnesium toxicity, but 30 mL/hr is within the acceptable range. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.
A primary healthcare provider prescribes an intravenous infusion of magnesium sulfate for a client with preeclampsia. What baseline assessment is essential before the nurse initiates the infusion? 1 Serum glucose 2 Respiratory rate 3 Body temperature 4 Level of consciousness
2, Respiratory rate Magnesium sulfate toxicity depresses respiration; therefore it is essential to obtain a baseline respiratory rate before initiating therapy. The serum glucose level is unrelated to magnesium sulfate toxicity. Deviations in temperature do not indicate magnesium sulfate toxicity. A decreased level of consciousness may indicate worsening preeclampsia, not magnesium sulfate toxicity.
A client who received intravenous magnesium sulfate for preeclampsia gives birth. What clinical finding in the newborn indicates to the nurse that magnesium sulfate toxicity may have occurred? 1 Pallor 2 Tremor 3 Hypotonia 4 Tachycardia
ANS: 3, Hypotonia Hypotonia occurs with magnesium sulfate toxicity because of skeletal and smooth muscle relaxation. Pallor, tremor, and tachycardia are not signs of magnesium sulfate toxicity.
A nurse is caring for a postpartum client who had abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
4 Bleeding at the venipuncture site 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 client who has experienced a severe abruptio placentae asks the nurse why there was so much bleeding. What should the nurse consider as the cause of the heavy bleeding before responding in language that the client will understand? 1 Polycythemia 2 Thrombocytopenia 3 Hyperglobulinemia 4 Hypofibrinogenemia
4, Hypofibrinogenemia Clotting defects are common in moderate and severe abruptio placentae because of the loss of fibrinogen caused by copious internal bleeding. An excessive amount of red blood cells is not related to the depletion of fibrinogen. The bleeding with abruptio placentae is caused by depletion of fibrinogen, not thrombocytes (platelets). Excessive globulin in the blood is unrelated to clotting.
What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1 Bed rest with sedation 2 Trendelenburg position and hydration 3 Preparation for emergency cesarean birth 4 External fetal monitoring and oxygenation
4, External fetal monitoring and oxygenation Fetal monitoring and oxygen administration should be instituted to protect the fetus. Some placental separation has occurred, and it may progress further. Sedation is contraindicated; it may further stress an already compromised fetus. The Trendelenburg position may shift the heavy uterus against the diaphragm and lead to compromised maternal respiratory function, further depriving the fetus of oxygen. Hydration is not a priority at this time. Further assessment of fetal status and progression of abruption placentae is needed before a cesarean birth is considered.
A nurse is monitoring a client with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55 beats/min, a respiratory rate of 10 breaths/min, and a flushed face. What are the next nursing actions? 1 Continuing the infusion and notifying the primary healthcare provider 2 Stopping the infusion and starting an infusion of dextrose and water 3 Continuing the infusion and documenting the findings in the clinical record 4 Decreasing the rate of the infusion and obtaining blood for a magnesium level
2 Stopping the infusion and starting an infusion of dextrose and water The client's slow pulse, respirations, and flushed face are signs of magnesium sulfate toxicity. The infusion should be stopped and the intravenous site maintained with an infusion of dextrose 5% in water because an antagonist (calcium gluconate) may be prescribed. Continuing the infusion and notifying the primary healthcare provider is unsafe because continuing the infusion will make the central nervous system (CNS) depression more severe. The primary healthcare provider should be notified after the infusion has been stopped.
A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. What should the nurse assess the client for? 1 Bright-red vaginal bleeding and multiple clots 2 Uterine tenderness and increased fetal activity 3 Cessation of contractions and decreased uterine size 4 Concealed hemorrhage and fetal heart rate accelerations
2, Uterine tenderness and increased fetal activity When the placenta initially separates, the fetus may become hyperactive as a response to acute hypoxia; the uterus is tender because of the accumulation of blood at the abrupted placental site. If bleeding occurs, it is dark red or port wine colored and usually does not clot. The uterus generally enlarges because of an accumulation of blood at the placental site. It is difficult to assess a client for concealed hemorrhage; the fetus must first be assessed for fetal heart tones to determine viability, not for increases or decreases in the heart rate.
A client with severe preeclampsia who was admitted to the high-risk unit anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond? 1 "There's no way of telling at this time what the outcome will be." 2 "If you do what the primary healthcare provider tells you to do, everything will progress normally." 3 "The baby will probably be all right. Did you know that the amniotic fluid provides protection?" 4 "We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?"
4 "We'll be constantly monitoring your baby's condition. I'll let you listen to the baby's heartbeat." Telling the client that the baby's condition will constantly be monitored reassures the client of the well-being of the fetus at the moment and indicates that the nurses are aware of and are monitoring the fetus's status. Saying that there is no way to know the outcome does not provide the mother with any reassurance of the status of the fetus or that anything is being done to monitor the fetus. Promising that the baby will be all right provides false reassurance; amniotic fluid will not protect the fetus if the mother has a seizure. Suggesting that everything will progress normally if the client follows the primary healthcare provider's instructions provides false reassurance; following instructions does not guarantee a healthy newborn.
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. 1 Absence of the knee-jerk reflex 2 Urine output of 100 mL/hr 3 Blood pressure of 140/90 mm Hg 4 Apical pulse of 80 beats/min 5 Respiratory rate of 11 breaths/min
ANS: 1, 5 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.
While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? 1 Reveals her level of consciousness 2 Reveals the mobility of the extremities 3 Reveals the response to painful stimuli 4 Identifies the potential for respiratory depression
ANS: 4 Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL.
The HELLP syndrome is a severe complication of preeclampsia that can occur, even in the post-delivery period. This complication is characterized by (select all that apply): 1 Thrombocytopenia 2 Hypotension 3 Decreased hemoglobin 4 Elevated AST and ALT levels 5 High white blood cell count 6 Increased bilibrubin 7 Right upper quadrant pain
Ans: 1, 3, 4, 6, 7 Thrombocytopenia: The vasospasms of preeclampsia cause vascular damage; platelets aggregate at the intravascular damage sites, resulting in a severe decrease in the number of circulating platelets. Decreased hemoglobin: The vasospasms of preeclampsia cause vascular damage. Red cell hemolysis occurs as blood passes through damaged vessels. Destruction of red blood cells results in a drop in hemoglobin. Elevated AST and ALT levels: As part of the HELLP syndrome, fibrin deposits in the liver obstruct hepatic blood flow. This results in an elevation in the liver enzymes, AST and ALT. Increased bilirubin: The vasospasms of preeclampsia cause vascular damage. Red cell hemolysis occurs as blood passes through damaged vessels. Hemolyzed red blood cells release bilirubin, and serum bilirubin level increases. RUQ pain: With the HELLP syndrome, fibrin deposits in the liver obstruct hepatic blood flow, resulting in painful abdominal distention.
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? 1 Call the client's mother and request a verbal consent. 2 Proceed with the preparation and forgo written consent. 3 Have the surgeon and attending primary healthcare provider sign the consent form. 4 Sign the consent form and have the nurse manager countersign the form.
3, Have the surgeon and attending primary healthcare provider sign the consent form. The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first.
A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows fetal bradycardia, and a change is seen in the contour of the client's abdomen. What is the nurse's priority intervention? 1 Checking the client's vital signs 2 Placing the client on her left side 3 Immediately placing an internal scalp electrode on the fetus 4 Alerting others regarding the need for immediate cesarean delivery
4, Alerting others regarding the need for immediate cesarean delivery Another nurse should be asked to notify the operating room staff, primary healthcare provider, anesthesiologist, and neonatal team to prepare. The client's nurse should monitor vital signs, watch for signs of hypotension and tachycardia, insert an indwelling catheter, and stay as calm as possible while explaining to the client that the staff are working together to bring about a safe outcome. The client is exhibiting signs of uterine rupture. An emergency cesarean birth is the priority. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the primary healthcare provider. Client history, fetal bradycardia, and change of abdominal contour indicate uterine rupture.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? 1 Cerebral hemorrhage 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock
4, Hypovolemic shock With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min
ANS: 1, 3, 4, 5 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.