MOM/BABY Exam 2
Rho(D) immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility
4. Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision for the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3. "I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen and it went away."
1. "My vision for the past 2 days has been really fuzzy." Rationale: Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia.
When assessing a premature PROM patient, the nurse knows that maternal fever as well as maternal and fetal tachycardia are clinical findings of this maternal complication: 1. Chorioamnionitis 2. Group B Streptococcus 3. Cholestasis 4. Polyhydramnios
1. Chorioamnionitis Rationale: Chorioamnionitis is the most common maternal complication of preterm PROM characterized by maternal and fetal tachycardia and maternal fever. Uterine tenderness and purulent amniotic fluid in the absence of another infection are also symptoms. Mothers with Group B Streptococcus do not have symptoms and it is diagnosed through testing. Cholestasis is a liver disease in pregnancy that causes maternal itching, and polyhydramnios is an increase in amniotic fluid. These would not cause the clinical findings provided.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery
1. Delivery of the fetus Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae.
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? 1. Maternal infection 2. Gestational hypertension 3. Gestational diabetes mellitus 4. Consumption of recent high-sugar snack
1. Maternal infection Rationale: The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to approximately 110 to 160 beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect the fetal heart rate but are not the most likely causes.
The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? 1. Increased insulin 2. Decreased insulin 3. Increased caloric intake 4. Decreased protein intake
1. increased insulin Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric and protein intake is not affected by diabetes.
The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate.
2. Clear and maintain an open airway Rationale: The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.
The nurse is administering Magnesium Sulfate for neuroprotection for a patient who is 30.4 weeks gestation in preterm labor. The nurse knows to frequently assess the following to identify Magnesium toxicity. Select all that apply. 1. Uterine Tone 2. Deep Tendon Reflexes 3. Respiratory Status 4. Level of Consciousness 5. Clonus
2. Deep Tendon Reflexes 3. Respiratory Status 4. Level of Consciousness Rationale: Signs of Magnesium toxicity include respiratory depression, altered level of consciousness including lethargy and slurred speech, and the absence of deep tendon reflexes. Clonus is a sign of hyperreflexia assessed in preeclampsia. Effects of Magnesium on uterine tone is not a sign of toxicity.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.
2. Massage the fundus until it is firm. Rationale: If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
3. Increased efficiency of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate
3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate Rationale: Oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a non-reassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some obstetricians prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.
A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? 1. Placenta previa 2. Polyhydramnios 3. Abruptio placentae 4. Gestational hypertension
3. Abruptio placentae Rationale: Trauma increases the incidence of miscarriage, preterm labor, abruptio placentae, and stillbirth. Careful evaluation of mother and fetus after any incident of trauma is essential. Placenta previa indicates that a placenta is implanted in the lower uterine segment near or over the internal cervical os. Risk factors that may precipitate placenta previa are not related to a traumatic event. Polyhydramnios is a term for excessive amniotic fluid, which would develop over time and not be a result of trauma. Although a motor vehicle crash may increase a woman's blood pressure, she would not be a candidate for gestational hypertension only because of the traumatic event.
The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per PHCP prescription and per agency protocol.
3. Perform a vaginal examination every shift. Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1. Tongue blade 2. Percussion hammer 3. Potassium chloride injection 4. Calcium gluconate injection
4. Calcium gluconate injection Rationale: Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate.
Which is the priority nursing action for the client with an ectopic pregnancy? 1. Assessing urine for proteinuria 2. Checking the electrolyte values 3. Monitoring for signs of infection 4. Monitoring the pulse and blood pressure
4. Monitoring the pulse and blood pressure Rationale: Nursing care for a client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate and a drop in blood pressure are indicators of shock. Proteinuria may be associated with preeclampsia, and an elevation in temperature is an indicator of infection. Electrolyte values are unrelated to ectopic pregnancy.
The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision.
4. The client complains of a headache and blurred vision Rationale: If the client complains of a headache and blurred vision, the PHCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.
