Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? -Assess the client's vital signs. -Administer oxygen to the client. -Obtain a surgical consent from the client. -Provide emotional support to the client and significant other.
Assess the client's vital signs. A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
Preeclampsia without Severe Features Blood Pressure? Seizures/coma? Hyperreflexia? Other signs and symptoms?
Blood pressure: >140/90 mm Hg after 20 weeks' gestation Seizures/coma? NO Hyperreflexia? NO Other signs and symptoms? N/A
Medications Related to Abortions Misoprostol (Cytotec)
Indication: Stimulates uterine contractions to terminate a pregnancy and to evacuate the uterus after abortion to ensure passage of all the products of conception Nursing Implications: -Monitor for side effects such as diarrhea, abdominal pain, nausea, vomiting, and dyspepsia. -Assess vaginal bleeding, and report any increased bleeding, pain, or fever. -Monitor for signs and symptoms of shock, such as tachycardia, hypotension, and anxiety.
A pregnant woman at 12 weeks' gestation comes to the office reporting she has begun minimal fresh vaginal spotting. She is distressed because her primary care provider indicates after examining her that they will "wait and see." Which response would be most appropriate from the nurse in answering this client's concerns? -Advise her to ask for a second care provider opinion. -Tell her that medication to prolong a 12-week pregnancy usually is not advised. -Explain that "wait and see" means that her care provider wants her to maintain strict bed rest. -Suggest she take an over-the-counter tocolytic just to feel secure.
Tell her that medication to prolong a 12-week pregnancy usually is not advised. Because many early pregnancy losses occur as the result of chromosome abnormalities, an aggressive approach to prolong these is not usually recommended. It would not be appropriate for the nurse to suggest an over-the-counter tocolytic, nor to tell the client that the care provider meant something else such as maintaining strict bed rest. Advising the client to seek a second opinion would not change the end results.
The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize? -Vaginal bleeding and no pain -Uterine contractions with vaginal mucus -Fundal height and fetal heart rate -Size and contour of the abdomen
Vaginal bleeding and no pain Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of placental abruption (abruptio placenta) accompanied by severe pain. This differentiates the two conditions. Uterine contractions with vaginal mucus may be indications of the start of labor with the mucus plug being discharged. The fetal heart rate, fundal height, and contour of the abdomen are normal components that are assessed during the labor process.
A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect? -ensures passage of all the products of conception -alleviates strong uterine cramping -suppresses the immune response to prevent isoimmunization -halts the progression of the abortion
ensures passage of all the products of conception Misoprostol is used to stimulate uterine contractions and evacuate the uterus after an abortion to ensure passage of all the products of conception. Rho(D) immune globulin is used to suppress the immune response and prevent isoimmunization. Page 664
n an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? -erythromycin ophthalmic ointment -silver nitrate solution -vitamin K -gentamicin ophthalmic ointment
erythromycin ophthalmic ointment Erythromycin ophthalmic ointment is the only drug approved by the U.S. Food and Drug Administration (FDA) for the prophylaxis of gonococcal neonatorum in the United States. Silver nitrate solution was once used for eye prophylaxis, but it is no longer used because it has little efficacy in preventing chlamydial eye disease. Vitamin K is used to promote blood clotting in the newborn. Gentamicin is not used for newborn eye prophylaxis.
A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? -grade 2 -grade 1 -grade 3 -grade 4
grade 2 The classifications for placental abruption (abruptio placentae) 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 blood pressure, 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. There is no grade 4.
Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with preterm premature rupture of membranes (PPROM) has completed how many weeks of gestation? -less than 37 weeks -less than 38 weeks -less than 39 weeks -less than 40 weeks
less than 37 weeks Preterm premature rupture of membranes (PPROM) is defined as the rupture of the membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation. PROM (premature rupture of membranes) refers to a woman who is beyond 37 weeks' gestation, has presented with spontaneous rupture of the membranes, and is not in labor.
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? -promote maternal D antibody formation. -prevent maternal D antibody formation. -stimulate maternal D immune antigens. -prevent fetal Rh blood formation.
prevent maternal D antibody formation. 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. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement? -"If I have changes in my vision, I will lie down and rest." -"I will weigh myself every morning after voiding before breakfast." -"I will count my baby's movements after each meal." -"If I have a severe headache, I'll call the clinic."
"If I have changes in my vision, I will lie down and rest." Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampsia and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia. The other choices are instructions which the client may be given to follow.
A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? -"Please come in now for an evaluation by your health care provider." -"Lie on your left side and drink lots of water and monitor the bleeding." -"If the bleeding lasts more than 24 hours, call us for an appointment." -"Bleeding during pregnancy happens for many reasons, some serious and some harmless."
"Please come in now for an evaluation by your health care provider." Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? -Check deep tendon reflexes. -Measure fundal height. -Palpate the fundus and check fetal heart rate. -Obtain a voided urine specimen and determine blood type.
Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? -Twin-to-twin transfusion syndrome (TTTS) -HELLP syndrome -TORCH syndrome -ABO incompatibility
Twin-to-twin transfusion syndrome (TTTS) When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.
A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition? -diabetes -hypertension -late maternal age -isoimmunization
diabetes Approximately 18% of all women with diabetes will develop hydramnios during their pregnancy. Hydramnios occurs in approximately 2% of all pregnancies and is associated with fetal anomalies of development.
A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements? -preeclampsia -placental abruption (abruptio placentae) -placenta previa -gestational hypertension
gestational hypertension Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Placental abruption (abruptio placentae), a separation of the placenta from the uterine wall; placenta previa (placenta covering the cervical os); and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.
A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply. -hyperthermia -hemolysis -elevated liver enzymes -leukocytosis -low platelet count
hemolysis elevated liver enzymes low platelet count The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? -oxytocin -promethazine -ondansetron -methotrexate
methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum. Page 663
A 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response? -"After a curettage procedure, it is recommended that you give your body some time to build up its stores." -"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." -"Since you are at the end of your reproductive years, it is suggested that you don't try to have any more pregnancies." -"You may need chemotherapy, so we don't want to risk pregnancy."
"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." Because of the risk of choriocarcinoma, the woman receives extensive treatment. Therapy includes baseline chest X-ray to detect lung metastasis, plus a physical exam (including a pelvic exam). Serum B-hCG levels weekly until negative results are obtained three consecutive times, then monthly for 6 to 12 months. The woman is cautioned to avoid pregnancy during this time because the increasing B-hCG levels associated with pregnancy would cause confusion as to whether cancer had developed. If after a year B-hCG serum titers are within normal levels, a normal pregnancy can be achieved.
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize? -A systolic blood pressure increase of 10 mm Hg -Weight gain of 1.2 lb (0.54 kg) during the past 1 week -A dipstick value of 2+ for protein -Pedal edema
A dipstick value of 2+ for protein The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.
Eclampsia Blood Pressure? Seizures/coma? Hyperreflexia? Other signs and symptoms?
Blood pressure: >160/110 mm Hg Seizures/coma? YES Hyperreflexia? YES Other signs and symptoms? Severe headache Generalized edema right upper quadrant or epigastric pain Visual disturbances Cerebral hemorrhage Renal failure HELLP
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 that 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? -Exposure to chemicals or radiation -Advanced maternal age -Chromosomal defects in the fetus -Faulty implantation
Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? -Rocking and talking to the infant -Swaddling the infant before returning to the crib -Feeding the infant more formula whenever she begins to fuss -Gently patting or stroking the infant's back
Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch, and gentle pats on the back all help calm a fussy infant.
Medications Related to Abortions Mifepristone (RU-486)
Indication: Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hours Nursing Actions: -Monitor for headache, vomiting, diarrhea, and heavy bleeding. -Anticipate administration of antiemetic prior to use to reduce nausea and vomiting. -Encourage client to use acetaminophen to reduce discomfort from cramping.
A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan? -Institute and maintain seizure precautions. -Institute NPO status. -Admit the client to the middle of ICU where she can be constantly monitored. -Plan for immediate induction of labor.
Institute and maintain seizure precautions. The woman with preeclampsia with severe features should be maintained on complete bed rest in a dark and quiet room to avoid stimulation. The client is at risk for seizures; therefore, institution and maintenance of seizure precautions should be in place.
A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)? -Onset of vaginal bleeding was sudden and painful -Fetus is in a breech position -Sonogram shows the placenta covering the cervical os -Uterus is soft between contractions
Onset of vaginal bleeding was sudden and painful Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.
Which action will the nurse avoid when performing basic care for a newborn male? -Inspecting the genital area for irritated skin -Palpating if testes are descended into the scrotal sac -Determining the location of the urethral opening -Retracting the foreskin over the glans to assess for secretions
Retracting the foreskin over the glans to assess for secretions The foreskin in male newborns does not normally retract and should not be forced. The nurse will inspect the genital area for irritated skin to prevent and/or treat possible skin irritations. The nurse will palpate the testes to determine if the newborn has cryptorchidism. It is important to verify that the urethral opening is at the tip of the glans and not on the dorsal or ventral sides as these would need intervention. This can be accomplished without overmanipulating the foreskin.
Which statement is false regarding bathing the newborn? -To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. -Bathing should not be done until the newborn is thermally stable. -While bathing the newborn, the nurse should wear gloves. -Mild soap should be used on the body and hair but not on the face.
To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.
While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? -bruising from the birth process -an immature autoregulation of blood flow -an allergic reaction to the soap used for the first bath -concentration of immature blood vessels
concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns. An allergic reaction would be more generalized and would not be salmon-colored.
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? -cord compression -fetal distress related to hypoxia -infection -central nervous system (CNS) involvement
fetal distress related to hypoxia When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.
A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: -hydatidiform mole. -ectopic pregnancy. -placenta accrete. -hydramnios.
hydatidiform mole. Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.
Which measure would the nurse include in the plan of care for a woman with prelabor rupture of membranes if her fetus's lungs are mature? -reduction in physical activity level -observation for signs of infection -administration of corticosteroids -labor induction
labor induction With prelabor rupture of membranes (PROM) in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature.
A woman at 35 weeks' gestation with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? -preterm rupture of membranes followed by preterm birth -development of eclampsia -hemorrhaging -development of gestational trophoblastic disease
preterm rupture of membranes followed by preterm birth Even with precautions, in most instances of hydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.
A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time? -premature birth -hypertension -spontaneous abortion (miscarriage) -preterm labor
spontaneous abortion (miscarriage) The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.
Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? -"Physiologic jaundice usually begins in the first week after birth." -"Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." -"Breastfed babies need supplements of glucose water to help lower bilirubin levels." -"The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."
"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.
A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse? -"Your spontaneous bleeding is not work-related." -"It is hard to know why a woman bleeds during early pregnancy." -"I can understand your need to find an answer to what caused this. Let's talk about this further." -"Something was wrong with the fetus."
"I can understand your need to find an answer to what caused this. Let's talk about this further." Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
A 16-year-old client was at 12 weeks' gestation when she gave birth to a fetus last week. The client has come to the office for follow-up and, while waiting in an examination room, notices that on the schedule is written her name and "follow-up of spontaneous abortion." The client is upset about what is written on the schedule. How can the nurse best explain this terminology? -"Spontaneous abortion is the medical name for a miscarriage." -"Abortion is a medical term for any interruption of pregnancy before a fetus is viable." -"Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy." -"Oh, that just means it was a miscarriage."
"Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy." Abortion is a medical term for any interruption of a pregnancy before a fetus is viable, but it is better to speak of these early pregnancy losses as spontaneous abortions to avoid confusion with intentional terminations of pregnancies. The other responses are correct, but they do not provide the client with the most complete nor reassuring answer.
A client reporting she recently had a positive pregnancy test has reported to the emergency department stating one-sided lower abdominal pain. The health care provider has prescribed a series of tests. Which test will provide the most definitive confirmation of an ectopic pregnancy? -Quantitative human chorionic gonadotropin (hCG) test -Qualitative human chorionic gonadotropin (hCG) test -Pelvic examination -Abdominal ultrasound
Abdominal ultrasound An ectopic pregnancy refers to the implantation of the fertilized egg in a location other than the uterus. Potential sites include the cervix, uterus, abdomen, and fallopian tubes. The confirmation of the ectopic pregnancy can be made by an ultrasound, which would confirm that there was no uterine pregnancy. A quantitative hCG level may be completed in the diagnostic plan. hCG levels in an ectopic pregnancy are traditionally reduced. While this would be an indication, it would not provide a positive confirmation. The qualitative hCG test would provide evidence of a pregnancy, but not the location of the pregnancy. A pelvic exam would be included in the diagnostic plan of care. It would likely show an enlarged uterus and cause potential discomfort to the client but would not be a definitive finding.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure? -Contraction test -Nonstress test -Biophysical profile -Amniocentesis
Amniocentesis 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 incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered. Page 693
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? -Test the newborn for HIV -Bathe the newborn thoroughly -Administer zidovudine -Assist the mother to breastfeed
Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.
When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia? -Bradycardia -Hyperglycemia -Metabolic alkalosis -Shivering
Bradycardia Bradycardia is an indicator that the neonate is hypothermic. A cold infant may develop acidosis as a result of metabolism of brown fat. Newborns do not shiver when cold. Hyperglycemia and metabolic alkalosis are not signs or consequences of hypothermia.
Medications Related to Abortions Rh(D) immunoglobulin (Gamulin, HydroRho-D, RhoGAM, MICRhoGAM)
Indication: Suppresses immune response of nonsensitized Rh-negative clients who are exposed to Rh-positive blood to prevent isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies. Nursing Actions: -Administer intramuscularly in deltoid area. -Give only MICRhoGAM for abortions and miscarriages <12 weeks unless fetus or father is Rh-negative (unless client is Rh-positive, Rh antibodies are present). -Educate woman that she will need this after subsequent deliveries if fetuses are Rh-positive; also check lab study results prior to administering the drug.
The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? -Use of pass codes onto the unit -Use of monitor attached to babies -Use of cameras at all doors -Cooperation by the parents with the hospital policies
Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.
Medications Related to Abortions PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2)
Indication: Stimulates uterine contractions, causing expulsion of uterine contents; expels uterine contents in fetal death or missed abortion during second trimester; effaces and dilates the cervix in pregnancy at term Nursing Actions: -Bring gel to room temperature before administering. -Avoid contact with skin. -Use sterile technique to administer. -Keep client supine for 30 minutes after administering. -Document time of insertion and dosing intervals. -Remove insert with retrieval system after 12 hours or at the onset of labor. -Explain purpose and expected response to client.
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? -Monitor the client's beta-hCG level. -Monitor the mass with transvaginal ultrasound. -Monitor the client's vital signs and bleeding. -Monitor the fetal heart rate (FHR).
Monitor the client's vital signs and bleeding. A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending abortion. Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity? -Lung sounds -Oxygen saturation -Reflexes -Magnesium sulfate level
Reflexes Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.
A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP? -elevated lipoproteins -hemolysis -liver enzyme elevation -low platelet count
elevated lipoproteins The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.
A woman at 9 weeks' gestation was unable to control the nausea and vomiting of hyperemesis gravidarum through conservative measures at home. With nausea and vomiting becoming severe, the woman was omitted to the obstetrical unit. Which action should the nurse prioritize? -bed rest with bathroom privileges -instruct on NPO status -establish IV for rehydration -administration of antiemetics
establish IV for rehydration With severe nausea and vomiting the client may be dehydrated upon coming to hospital for assistance, so establishing an IV line is the priority intervention. This will also allow for hydration, and if needed, the administration of an antiemetic to bypass the gastrointestinal tract. Although the nurse will explain the NPO status to the client (so that vomiting may be brought under control) and the likelihood of being placed on bed rest with bathroom privileges, these teaching are not the priority.
A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination, there is an elevated human chorionic gonadotropin (hCG) level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition? -ectopic pregnancy -placenta previa -gestational trophoblastic disease -placental abruption (abruption placentae)
gestational trophoblastic disease The client is most likely experiencing gestational trophoblastic disease, or a molar pregnancy. In gestational trophoblastic disease, there is an abnormal proliferation and eventual degeneration of the trophoblastic villi. The signs and symptoms of molar pregnancy include brownish vaginal bleeding, elevated hCG levels, discrepancy between the uterine size and the gestational age, and absent fetal heart sounds. Placental abruption is characterized by premature separation of the placenta. Ectopic pregnancy is a condition where there is implantation of the blastocyst outside the uterus. In placenta previa, the placental attachment is at the lower uterine segment.
What would be the physiologic basis for a placenta previa? -a loose placental implantation -low placental implantation -a placenta with multiple lobes -a uterus with a midseptum
low placental implantation The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.
The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions would the nurse most likely include? Select all that apply. -maintaining NPO status for the first day or two -preparing the woman for insertion of a feeding tube -administering antiemetic agents -obtaining baseline blood electrolyte levels -monitoring intake and output
maintaining NPO status for the first day or two administering antiemetic agents obtaining baseline blood electrolyte levels monitoring intake and output When hospitalization is necessary, oral food and fluids are withheld to allow the gut to rest. Antiemetic agents are ordered to help control nausea and vomiting. The woman is likely to be dehydrated, so the nurse would obtain baseline blood electrolyte levels and administer intravenous fluid and electrolyte replacement therapy as indicated. Once the nausea and vomiting subside, oral food and fluids are gradually reintroduced. Total parenteral nutrition or a feeding tube is used to prevent malnutrition only if the client does not improve with these interventions.
During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition? -mild preeclampsia -gestational hypertension -severe preeclampsia -eclampsia
mild preeclampsia A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to be mildly preeclamptic when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart. A woman has passed from mild to severe preeclampsia when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a grand-mal seizure (tonic-clonic) or coma has occurred. Page 684
A nurse is providing care to a multiparous client. The client has a history of cesarean births. The nurse anticipates the need to closely monitor the client for which condition? -placenta accreta -placental abruption (abruptio placentae) -preeclampsia -oligohydramnios
placenta accreta Placenta accreta is a condition where the placenta attaches itself too deeply into the wall of the uterus. According to the literature, a cesarean birth increases the possibility of a future placenta accreta; the more cesarean births that are done, the greater the incidence. Placental abruption (abruptio placentae) occurs when the placenta becomes detached prematurely. Preeclampsia and oligohydramnios are nonrelated to previous cesarean births.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? -urine protein -ability to sleep -hemoglobin -respiratory rate
respiratory rate A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? -strong abdominal cramping -slight vaginal bleeding -closed cervical os -no passage of fetal tissue
strong abdominal cramping Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy? -high number of pregnancies -multiple gestation pregnancy -use of oral contraceptives -use of IUD for contraception
use of IUD for contraception Use of an IUD with progesterone has a known increased risk for development of ectopic pregnancies. The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple elective abortions. Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. Hormonal factors may play a role because tubal pregnancy occurs more frequently in women who take fertility drugs or who use progesterone intrauterine contraceptive devices (IUDs). A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.
The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? -within 30 minutes after birth, in the birthing area -within the first 2 to 4 hours, when the newborn reaches the nursery -prior to the newborn being discharged -24 hours after the newborn's birth
within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.
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 dilatation and curettage. The client looks frightened and confused and states that she does not believe in 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." -"I know that it is sad but the pregnancy must be terminated to save your life." -"The choice is up to you but the health care provider is recommending an abortion." -"You have experienced an incomplete miscarriage and must have the placenta and any other tissues cleaned out."
"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.
Preeclampsia with Severe Features Blood Pressure? Seizures/coma? Hyperreflexia? Other signs and symptoms?
Blood pressure: ≥160/110 mm Hg on two occasions at least 6 hours apart while on bed rest Seizures/coma? NO Hyperreflexia? YES Other signs and symptoms? Headache Oliguria Blurred vision, scotomata (blind spots) Pulmonary edema Thrombocytopenia (platelet count <100,000 platelets/mm3) Cerebral disturbances Persistent epigastric or right upper quadrant pain HELLP Progressive renal insufficiency
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate? -Encourage the client to be positive about the situation. -Continue to monitor the client's hyperemesis gravidarum. -Contact the health care provider to report the client's feelings. -Share the information with the client's family.
Contact the health care provider to report the client's feelings. The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family.
What special interventions would the nurse implement in a client who is carrying twin fetuses? -Schedule non-stress tests (NST) starting at 16 weeks. -Demonstrate to the client how to perform fetal movement counts after 32 weeks. -Assist the physician on doing uterine ultrasounds every 2 weeks to monitor fetal size and placental information. -Remind the client to monitor her intake since she does not need any more food for a multiple pregnancy than she would ingest for a singleton pregnancy.
Demonstrate to the client how to perform fetal movement counts after 32 weeks. A woman carrying a multiple gestation needs to keep up with how her fetuses are doing, and an excellent way to do that is by doing fetal movement counts, or "kick counts" as they are sometimes called. This starts at around 32 weeks' gestation for an uncomplicated pregnancy and continues until birth. Weekly or bi-weekly NSTs begin after 32 weeks. Obstetrical ultrasounds are done every 4 to 6 weeks after confirmation of a multiple fetal pregnancy. The client needs to increase her intake, along with her iron and folic acid intake, to provide adequate nutrition for both fetuses.
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 prepares to assess for which possible cause for this client's complaints? -Healthy pregnancy -Ectopic pregnancy -Molar pregnancy -Placenta previa
Ectopic pregnancy 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 healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant? -Bed rest for the next 4 weeks -Intravenous administration of a tocolytic -Immediate surgery -Internal uterine monitoring
Immediate surgery The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.
A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal? -Decrease blood pressure -Decrease protein in urine -Prevent maternal seizures -Reverse edema
Prevent maternal seizures The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.
A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first? -Administer oxygen to the client. -Notify the health care provider. -Reposition the client to left side. -Increase the rate of IV fluids.
Reposition the client to left side. The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.
