high risk ob
Which lab result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT) 2. A low fibrinogen level 3. An increased platelet count 4. An increased white blood cell count
2. Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.
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? 1. The client's clot formations will resolve in two days 2. The saturation of the client's dressings will be documented 3. The client will use lemon-glycerin swabs for oral care 4. The client's urine output will be > 30 mL per hour
4. 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.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome? Elevated blood glucose Elevated platelet count Elevated creatinine clearance Elevated hepatic enzymes
Elevated Hepatic Enzymes
Which collaborative treatment would the nurse anticipate in the client diagnosed with DIC? 1. Administer oral anticoagulants 2. Prepare for plasmapheresis 3. Administer fresh frozen plasma 4. Calculate the intake and output
3. Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets
A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? a) meperidine hydrochloride b) magnesium sulfate c) fresh-frozen platelets d) warfarin sodium
c) fresh-frozen platelets To stop the process of DIC, the underlying insult that began the phenomenon must be halted. Treatment includes fresh-frozen platelets or blood administration. The HCP also may prescribe heparin before the administration of blood products to restore the normal clotting mechanism. Immediate birth of the fetus is essential. Magnesium sulfate is given for pregnancy-induced hypertension or preterm labor. Heparin, not warfarin sodium, is used to treat DIC. Meperidine hydrochloride is used for pain relief.
A client in labor received an epidural for pain management. Before receiving the epidural, the client's blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client's blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), the nurse should: a) decrease the IV fluid rate. b) perform a vaginal examination. c) turn the client to her side. d) catheterize the client.
c) turn the client to her side.
A nurse is counseling a preeclamptic client about her diet. Which 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
c. Eat a well-balanced diet
The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention? a) The cervix is fully dilated. b) The client has not received anesthesia. c) The fetus is at 0 station. d) The membranes are intact.
d) The membranes are intact. Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at -1 station
A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm, completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor? a) Expulsive phase b) Latent phase c) Active phase d) Transitional phase
d) Transitional phase
When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? a) portable ultrasound machine b) oxytocin infusion solution c) disposable tongue blades d) padding for the side rails
d) padding for the side rails
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's 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) Disseminated intravascular coagulation (DIC). B) HELLP syndrome. C) Eclampsia. D) Idiopathic thrombocytopenia.
B) HELLP syndrome.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to: a) request local anesthesia for vaginal birth. b) remain in a side-lying position with the head elevated. c) breathe slowly after each contraction. d) avoid the use of analgesics for the labor pain.
b) remain in a side-lying position with the head elevated. The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted. Although breathing slowly during a contraction may assist with oxygenation, it would have no effect on cardiac emptying. It is essential that the laboring woman with cardiac disease be relieved of discomfort and anxiety. Effective intrapartum pain relief with analgesia and epidural anesthesia may reduce cardiac workload as much as 20%. Local anesthetics are effective only during the second stage of labor.
The nurse is caring for a client in labor who is receiving epidural anesthesia. The nurse assesses a blood pressure of 80/40 mm Hg. Which of the following interventions will the nurse include in the client's plan of care? a) Monitor the fetal heart rate b) Increase the client's fluid rate c) Increase the epidural infusion rate d) Turn off the client's epidural infusion
b) Increase the client's fluid rate A hypotensive crisis may occur after administering epidural anesthesia. The immediate intervention for this type of crisis is to increase the fluid rate.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? a) Notify the health care provider (HCP). b) Turn the client to her left side. c) Turn off the oxytocin infusion. d) Increase the maintenance IV fluids.
c) Turn off the oxytocin infusion. The client is experiencing uterine hyperstimulation from the oxytocin. The first intervention should be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and abnormal fetal heart patterns. Only after turning off the oxytocin should the nurse turn the client to her left side to better perfuse the mother and fetus. Then she should increase the maintenance IV fluids to allow available oxygen to be carried to the mother and fetus. When all other interventions are initiated, she should notify the HCP.
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which intervention would the nurse do first? a) Turn the client to her right side. b) Perform a sterile vaginal examination. c) Check the status of the fetal heart rate. d) Test the leaking fluid with nitrazine paper.
c) Check the status of the fetal heart rate. The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse's first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. Checking the fluid with nitrazine paper and vaginal examination are appropriate once the status of the fetus has been evaluated.
A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? a) Notify the health care provider (HCP) immediately, and prepare for emergency caesarean section. b) Perform vaginal exam to rule out umbilical cord prolapse. c) Document findings on the woman's medical record, and continue to monitor labor progress. d) Position woman on her left side, and administer oxygen via face mask.
c) Document findings on the woman's medical record, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations. Early decelerations are thought to be the result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decelerations do not require position change or oxygen, as they are not a sign of fetal distress. Variable decelerations are thought to be due to umbilical cord compression. Early decelerations are not emergent and do not require immediate reporting to the health care provider (HCP) or preparing for caesarean section.
