nursing

A postpartum mother has the following lab data recorded: Rh is negative, and rubella titer is positive. What is the appropriate nursing intervention?

Administer Rho(D) immune globulin within 72 hours. The rubella is a virus, and the mother has a positive titer indicating she is immune; this is important data for prenatal care and only has a bearing if the client were negative. The Rh is negative for the mother, and the infant status is unknown; to protect future pregnancies the mother should be given Rho(D) immune globulin.

A pregnant client arrives at the clinic for a regular antenatal check-up. Examinations and weight recording reveal a slow fetal weight gain. About which of the following pregnancy-related risks should the nurse alert the client?

Preterm labor Explanation: The nurse should alert the client with slowed fetal growth that she may experience a preterm labor. Preterm labor is common among women who show slowed fetal growth.

A pregnant client in her 35th week of gestation arrives at the clinic with complaints of abdominal pain and spotting. The ultrasound indicates that the placenta is partially covering the dilated internal os. The nurse interprets this as which type of placenta previa?

The nurse should classify the condition as type III placenta previa. In type III placenta previa, the placenta partially covers the dilated internal os. It is a major degree of placenta previa. In type I, the placenta is present at the lower uterine segment but not extending up to the internal os. In type II, the placenta extends up to the internal os but does not cover it. In type III, the placenta covers the dilated internal os partially. In type IV, the placenta covers the dilated internal os completely.

What is the drug methylergonovine maleate used for?

Uterine contraction Explanation: Methylergonovine maleate or carboprost tromethamine (Hemabate) are other medications that may be ordered to stimulate the uterine muscle to contract.

A client in her first trimester has just experienced a miscarriage. The nurse knows that which occurrence is the most likely cause of the miscarriage?

abnormal fetal development Explanation: The most frequent cause of miscarriage in the first trimester of pregnancy is abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration.

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

at 28 weeks' gestation and again within 72 hours after birth Explanation: To prevent isoimmunization, the woman should receive Rho(D) immune globulin at 28 weeks and again within 72 hours after birth.

A pregnant client in her 22nd week of gestation arrives at the health care facility reporting excessive vaginal bleeding and absence of fetal movements. She is diagnosed as having second trimester fetal loss. What would the nurse anticipate as the cause of second trimester fetal loss?

cervical incompetence Explanation: The nurse should identify cervical incompetence as the cause for second trimester fetal loss. Cervical incompetence is a condition where there is painless cervical dilatation and results in second trimester fetal loss or can progress to preterm premature rupture of membranes. Ectopic pregnancy, congenital malformations, and placenta previa are not involved in causing second trimester fetal loss. Ectopic pregnancy usually leads to first trimester fetal loss. Placenta previa is a condition in which there is implantation of the placenta to the lower uterine segment. Congenital malformations result in first trimester fetal loss.

A pregnant client with multiple gestation arrives at the maternity clinic for a regular antenatal check up. The nurse would be aware that client is at risk for which perinatal complication?

congenital anomalies Multiple gestation involves two or more fetuses. The perinatal complications associated with multiple pregnancy include preterm birth, maternal hypertension and congenital anomalies.

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?

dark red, "clumpy" vaginal discharge Explanation: If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.

A woman with severe preeclampsia is receiving magnesium sulfate. The woman serum magnesium level is 9.0mEq/L. Which finding would the nurse most likely note?

diminished reflexes Explanation: Diminished or absent reflexes occur when a client develops magnesium toxicity, serum levels greater than 8.0 mEq/L.

A client visits a health care facility reporting amenorrhea for 10 weeks, fatigue, and breast tenderness. Which additional signs and symptoms suggest the presence of molar pregnancy? Select all that apply.

elevated hCG levels absence of fetal heart sound hyperemesis gravidarum Explanation: The signs and symptoms of molar pregnancy include an elevated hCG level, absence of fetal heart sounds, and hyperemesis gravidarum. Whitish discharge from the vagina and dyspareunia (painful sexual intercourse) are seen in cases of infection not in molar pregnancy. In molar pregnancy, a brownish vaginal bleeding is seen.

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which area because of the woman's increased risk?

preeclampsia Explanation: Women with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.

A pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's medical record, the nurse would expect which finding?

sudden dark, vaginal bleeding Explanation: 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. Bright red vaginal bleeding 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 young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?

threatened abortion Explanation: Spontaneous abortion occurs along a continuum: threatened, inevitable, incomplete, complete, missed. The definition of each category is related to whether or not the uterus is emptied, or for how long the products of conception are retained.

A nurse is assessing a client diagnosed with mild preeclampsia. The nurse suspects that the client has developed severe preeclampsia based on which finding?

urine output of less than 400 mL/24 hours Explanation: Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 5 g in 24 hours, oliguria of less than 400 mL in 24 hours, cerebral and visual symptoms, and rapid weight gain. Mild facial edema or hand edema occurs with mild preeclampsia. Proteinuria in severe preeclampsia is greater than 500 mg/24 hours.

A woman who is 31 weeks pregnant presents at the emergency department with bright red vaginal bleeding. She says the onset of the bleeding was sudden and she has no pain. The nurse is most likely to assist the primary care provider or technician with which exam?

a transvaginal ultrasound Explanation: The use of a transvaginal ultrasound is the diagnostic test of choice; it is 100% accurate in prediction of placenta previa, while abdominal ultrasound is only 95% accurate. A digital cervical exam is contraindicated in this client, and the scenario described does not indicate the need for a blood transfusion.

When providing counseling on early pregnancy loss, the nurse should discuss which factor as the most common cause for spontaneous abortion?

chromosomal abnormality Explanation: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done, and the mother should feel no fault. The nurse needs to educate the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.

A nurse is explaining to a group of nursing students that eclampsia or seizures in pregnant women are preceded by an acute increase in maternal blood pressure. What are features of an acute increase in blood pressure? Select all that apply.

proteinuria hypereflexia blurring of vision

A woman in labor is at risk for abruptio placentae. Which assessment would most likely lead the nurse to suspect that this has happened?

sharp fundal pain and discomfort between contractions Explanation: An abruptio placentae refers to premature separation of the placenta from the uterus. As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation. Painless vaginal bleeding and a fall in blood pressure are indicative of placenta previa. Pain in a lower quadrant and increased pulse rate are indicative of an ectopic pregnancy. Hypertension and oliguria are indicative of preeclampsia.

A 28-year-old woman presents in the emergency department with severe abdominal pain. She has not had a normal period for 2 months, but she reports that that is not abnormal for her. She has a history of endometriosis. What might the nurse suggest to the primary care provider as a possible cause of the client's abdominal pain?

Ectopic pregnancy can present with severe unilateral 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 pregnant client is admitted to a health care facility after she develops HELLP syndrome. Which of the following would the nurse most likely assess? Select all that apply

Nausea and vomiting Generalized edema Right upper quadrant pain Explanation: A pregnant client who develops HELLP syndrome may complain of nausea and vomiting, generalized edema, and right upper quadrant pain in the abdomen. Watery diarrhea and excessive weight loss are not symptoms of HELLP syndrome. Instead, weight gain may be seen in HELLP syndrome.

A client reports to her obstetrician a significant amount of bright red, painless vaginal bleeding. A sonogram reveals that her placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measures should the nurse initiate? Select all that apply.

Place the woman on bed rest in a side-lying position. Determine from the client the time the bleeding began and about how much blood has been lost. Obtain baseline vital signs. Continue to assess blood pressure every 5 to 15 minutes. Attach external monitoring equipment to record fetal heart sounds. Explanation: With the exception of performing a pelvic examination, all of the answers are appropriate immediate care measures for the client with placenta previa. The nurse should never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, possibly fatal to both mother and child.

A client with a multiple pregnancy has come to a health care facility for a regular antenatal check-up. When educating the client on pregnancy, about which of the following complications should the nurse inform the client?

Placental dysfunction Explanation: The nurse should inform the client that placental dysfunction might occur as a complication of multiple pregnancies. Other complications of multiple pregnancies include preterm labor, hypertension, anemia, cord abnormalities, congenital anomalies, intrauterine growth restriction, and low birth weight. Hypertension, and not hypotension, is seen in multiple pregnancies. Fetal macrosomia is not seen in cases of multiple gestation. Constipation, and not diarrhea, is also seen as a complication of multiple pregnancies. This is due to the decreased functioning of the gastrointestinal system in multiple pregnancy.

A pregnant client in her 34th week of gestation is diagnosed with amnionitis due to group B streptococcus. The nurse monitors the client closely based on the understanding that the client is at risk for which of the following?

Preterm birth Explanation: The complication that may occur due to infection of pregnant clients with GBS is preterm birth. Pregnant clients infected with GBS may be asymptomatic or they may develop urinary tract infection, amnionitis and endometritis. Fetal hydrops, fetal macrosomia and fetal neural tube defects are not complications occurring with the infection of a pregnant client with GBS. Infection with parvovirus during pregnancy may result in fetal non-immune hydrops. Fetal macrosomia is seen in gestational diabetes. Fetal neural tube defect is seen due to folic acid deficiency in pregnant clients.

The nurse must stress to which client being discharged for home the critical need to return for monthly follow-up visits?

a woman who has experienced a molar pregnancy. Explanation: Molar pregnancies can indicate the possibility of developing malignancy. The woman will need close observation and follow-up for the year following the diagnosis. Follow-up visits after an ectopic pregnancy or a complete spontaneous abortion are typically scheduled at six weeks, not monthly. A woman who is Rh negative does not need a follow-up visit because of her Rh status.

Which finding would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease?

gestational hypertension, hyperemesis gravidarum, absence of FHR Explanation: Gestational trophoblastic disease may be manifested by early development of preeclampsia (gestational hypertension), severe morning sickness due to high hCG levels, and absence of fetal heart rate or activity. There is no fetus, so quickening and evidence of a fetal skeleton would not be seen. The abdominal enlargement is greater than expected for pregnancy dates, but hCG, not hPL, levels are increased

The nurse through assessment can best differentiate between placenta previa and abruptio placentae by which sign or symptom?

uterine tone and contractions of the uterus Explanation: With placenta previa the bleeding is often bright red and painless; with abruptio placentae the bleeding is usually dark and painful. The uterus is firm and hard and painful with the abruption; the uterus is often soft and lacks tone with the previa. The contractions of the uterus, low back pain, or the shape of the abdomen do not help to distinguish between placenta previa and abruption placentae.