Ch. 19 Prep U

A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?

chromosomal defects in the fetus Rationale: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason.

A primipara at 36 weeks' gestation is is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?

a dipstick value of 2+ for protein Rationale: The increasing amount of protein in the urine is a concern that the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider.

The nurse is caring for a client who has remained stable at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?

vaginal bleeding and no pain Rationale: Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of placental abruption accompanied by severe pain. Uterine contractions with mucus may be indications of the start of labor with the mucus plug being discharged.

A 28-year old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepared to assess for which possible cause for this client's complaints?

Ectopic pregnancy Rationale: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered.

A client at 25 weeks' gestation with a bp of 152/99 mmHg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next?

notify the health care provider Rationale: the client is exhibiting a sign of gestational hypertension, elevated bp greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The HCP should be notified to assess the client further.

A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding the client?

preterm rupture of membranes followed by preterm labor Rationale: even with precautions, in most instances of polyhydramnios, there will be preterm rupture of membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilation and curettage (D&C). the client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best?

unfortunately the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications.

A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to have Rh positive blood. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

amniocentesis Rationale: amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatability.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is a priority?

assessing the amount and color of the bleeding Rationale: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

A pregnant client is brought to the health care facility with signs of premature rupture of the membranes (PROM). Which condition(s) and complication(s) are associated with PROM? Select all that apply prolapsed cord placental abruption spontaneous abortion placenta previa preterm labor

prolapsed cord placental abruption preterm labor Rationale: The associated conditions and complications of premature rupture of the membranes are infection, prolapsed cord, placental abruption (abruptio placentae), and preterm labor. Spontaneous abortion (miscarriage) and placenta previa are not associated conditions or complications of premature rupture of the membranes.

A client whose membranes have prematurely ruptured is admitted to the hospital. Which nursing intervention is a priority?

Routine monitoring of vital signs Rationale: rupture of the membranes without the onset of labor places the woman at risk for infection. Antibiotic therapy is often initiated as well, depending upon closeness of labor initiation (naturally or induced). The fetus will be monitored on a regular basis and then continuously when the labor process occurs.

A client has been admitted to the hospital with a diagnosis of preeclampsia with severe features. Which nursing intervention is the priority?

confine the client to bed rest in a darkened room Rationale: with preeclampsia with severe features, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect?

firm, rigid uterus on palpation Rationale: The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A woman at 10 weeks' gestation comes to the clinic for an evaluation. Which assessment finding should the nurse prioritize?

fundal height measurement of 18cm Rationale: a fundal height of 18 cm is larger than expected and should be further investigated for gestational trophoblastic disease (hydatidiform mole). One of the presenting signs is the uterus being larger than expected for date.

A client has been admitted with placental abruption. She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptia placentae?

grade 2 Rationale: The classification for placental abruption are grade 1 (mild)-minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress. Grade 2 (moderate)- moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal bp, maternal tachycardia. Grade 3 (severe)- absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy.

A nurse is reviewing the medical record of a client. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which condition?

low-lying placenta Rationale: Placenta previa is currently classified with two terms "placenta previa" and "low-lying placenta". If the placental edge is less than 2cm from the internal os but does not cover it, the placenta is reported as low-lying. If the placental edge covers the internal os, it is labeled as a placenta previa.

A nurse is teaching a group of pregnant women about bleeding that can occur early in pregnancy. The nurse determines that additional teaching is needed when the group identifies which condition as a common cause?

placenta previa Rationale: the three most common causes of hemorrhage during the first half of pregnancy are spontaneous abortion (miscarriage), ectopic pregnancy, and GTD. Placenta previa occurs in the later weeks of pregnancy.

A 24 year old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation Rationale: because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus.

A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which finding would lead the nurse to suspect that the fallopian tube has ruptured?

referred shoulder pain Rationale: referred pain to the shoulder area indicated bleeding into the abdomen caused by phrenic nerve irritation when a tubal pregnancy ruptures. Vaginal spotting, nausea, and breast tenderness are typical findings of early pregnancy and an unruptured ectopic pregnancy