OB Exam 2
A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus
B. Feeling of warmth The nurse should tell the client to expect a feeling of warmth all over her body while the magnesium sulfate is infusing.
A nurse is counseling a 45-year-old pregnant woman regarding the risks associated with amniocentesis. Which of the following is NOT a risk associated with this procedure? A. Infection B. Miscarriage C. Leakage of amniotic fluid D. Seizure E. Vaginal bleeding
D. Seizure
A nurse is providing information to a client who is 34 weeks pregnant about a scheduled non-stress test. Which statement by the nurse is most accurate? A. "We will connect you to a monitor and check your baby's movements and heart rate over the course of 30 minutes." B. "You will have an ultrasound that watches your baby's movements and records his heart rate." C. "The doctor will give you medicine to stimulate contractions, and then we will measure your baby's heart rate in response." D. "The doctor will take a small sample of fluid from the amniotic sac and test it for genetic changes."
A. "We will connect you to a monitor and check your baby's movements and heart rate over the course of 30 minutes."
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine
A. 480 mL urine output in 24 hr When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.
A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome
A. A newborn who is large for gestational age Large for gestational age (LGA) newborns have a weight at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at an increased risk of hypoglycemia. Other newborns at risk of hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.
A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobin after the procedure D. Instruct the client to take a deep breath and hold it during the entry of the needle
A. Apply an external fetal monitor to the client The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and monitor for changes.
A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? A. Continue to monitor the fetal heart tracings B. Elevate the client's legs C. Increase the rate of the maintenance IV fluid D. Administer oxygen via facemask
A. Continue to monitor the fetal heart tracings Early decelerations reflect fetal head compression and are a benign and normal finding during labor. The nurse should reassure the client and should continue to monitor the fetal heart tracings.
A nurse is assessing a client who has preeclampsia with severe features and is receiving IV magnesium sulfate. The client exhibits absent deep tendon reflexes and has a respiratory rate of 10/min. Which of the following actions should the nurse take? A. Discontinue the medication infusion. B. Prepare the client for an emergency cesarean birth. C. Determine the client's current blood glucose level. D. Administer an additional loading dose of the medication.
A. Discontinue the medication infusion. A. Magnesium toxicity is manifested as bradypnea, or a respiratory rate of less than 12/min, and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate should be administered immediately via IV.
A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease
B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed.
A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take? A. Slow the IV infusion rate B. Assist the client to a lateral position C. Assess the bladder for urinary retention D. Initiate an oxytocin infusion
B. Assist the client to a lateral position A late deceleration is a variation in the fetal heart rate that results from uteroplacental insufficiency. Side-lying positioning helps improve uteroplacental blood flow.
Which of the following situations constitutes an indication for a non-stress test? (Select all that apply.) A. Maternal hypothyroidism B. Decreasing fetal movement C. Twins or triplets D. Maternal fever E. At 12 week visit.
B. Decreasing fetal movement C. Twins or triplets A non-stress test can be performed on a pregnant client as a non-invasive test to evaluate fetal response to in utero stimulation, such as fetal movement. A non-stress test is typically performed after 28 weeks' gestation and is used to assess fetal response in certain situations, such as during preterm labor or when twins or triplets are present. If there is decreasing fetal movement, the provider may also order a non-stress test to determine the baby's response..
A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL
B. Deep tendon reflexes 4+ Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures.
A nurse is caring for a client in labor and observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Notify the provider B. Document the findings and continue to monitor C. Administer oxygen via face mask D. Assist with a sterile speculum examination
B. Document the findings and continue to monitor Early decelerations are a normal and benign finding caused by compression of the fetal head during uterine contractions.
A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in a semi-Fowler's position D. Provide glucose via oral hydration or IV
B. Increase the rate of the primary IV infusion Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well.
A nurse is teaching a client who is at 24 weeks of gestation and scheduled for an amniocentesis procedure. Which of the following client statements indicates an understanding of the teaching? A. "I will lie on my right side during this test." B. "I cannot eat or drink anything for 24 hours prior to this procedure." C. "I must urinate prior to the procedure." D. "I will be given medication to put me to sleep during this procedure."
C. "I must urinate prior to the procedure." During an amniocentesis, a needle is inserted through the maternal abdomen and there is a risk for puncture. The client's bladder should be empty prior to the procedure to allow for better visualization of the gestational sac and to reduce this risk.
A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection
C. Administer immune globulin to the client to prevent fetal isoimmunization Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure.
A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus
C. Prolapsed umbilical cord The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately.
A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."
D. "You will feel some mild discomfort during the procedure." During an amniocentesis, the client might feel slight uterine cramping when the needle comes into contact with the uterus. A local anesthetic is applied to the client's skin, so the client should not feel pain when the needle pierces the skin.
A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery
D. Prepare the client for an emergency cesarean delivery A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery.
A nurse is caring for a client who is in labor and has fetal heart tracings of variable decelerations. Which of the following actions should the nurse take? A. Request a prescription for oxytocin B. Administer oxygen at 2 L/min via nasal cannula C. Prepare for the insertion of an intrauterine balloon D. Reposition the client from side to side
D. Reposition the client from side to side Variable decelerations are caused by cord compression. Changing the client from side to side or assisting her into a knee-chest position might relieve cord compression and improve the variable decelerations.
A charge nurse on a labor and delivery unit is providing an inservice for staff about diagnostic tests used during pregnancy to measure fetal and maternal well-being. Which of the following examples will the charge nurse use as a common indication for non-stress test (NST) in a pregnant client? A. The client is 41 weeks gestation B. The client is 39 years old C. The client's first child had Down syndrome D. The client had an abnormal ultrasound
D. The client had an abnormal ultrasound A non-stress test (NST) is a procedure that is performed by attaching a fetal monitor to a pregnant client and recording the fetal heart rate and activities; the mother pushes a button whenever she feels the baby move. Of the options provided, a NST would most likely be indicated for a pregnant client who is past her due date.
A nurse is assessing a client who is receiving magnesium sulfate as a treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority? A. Respirations 16/min B. Urinary output 40 mL in 2 hr C. Reflexes +2 D. Fetal heart rate 158/min
B. Urinary output 40 mL in 2 hr Using the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority since they pose more of a threat to the client. As a result, the nurse should report the client's urinary output immediately. Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is <30 mL/hr. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth
A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder.
A nurse is preparing to perform a non-stress test. Which position would the nurse recommend that the client be placed in? A. Lateral position B. Supine position C. Semi Fowler's position D. High Fowler's position
A. Lateral position The client is placed in a lateral position to avoid vena cava compression.
A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? A. Place the client in a side-lying position B. Discontinue the oxytocin infusion C. Apply oxygen to the client via a face mask D. Check for umbilical cord prolapse
A. Place the client in a side-lying position According to evidence-based practice, the nurse should act quickly to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord.
A nurse is providing care for a client who is in the second stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? A. Prepare an amnioinfusion B. Place the client in a supine position C. Administer oxygen 2 L/min via nasal cannula D. Give a glucocorticoid
A. Prepare an amnioinfusion The nurse should prepare an amnioinfusion to decrease cord compression.
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory depression B. Hypothermia C. Hypoglycemia D. Jaundice
A. Respiratory depression Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.
A nurse is caring for a client who has severe preeclampsia and is receiving a magnesium sulfate IV infusion. The nurse should monitor the client for which of the following manifestations as a sign of magnesium sulfate toxicity? (Select all that apply.) A. Respiratory rate less than 12/min B. Excessive urinary output C. Hyperreflexic deep tendon reflexes D. Decreased level of consciousness E. Flushing and sweating
A. Respiratory rate less than 12/min D. Decreased level of consciousness Magnesium causes the cerebral blood vessels to dilate and can suppress the function of the central nervous system. A respiratory rate of less than 12/min is a manifestation of magnesium sulfate toxicity. Magnesium causes the cerebral blood vessels to dilate and can suppress the function of the central nervous system. A decreased level of consciousness is a manifestation of central nervous system depression and of magnesium sulfate toxicity.
A pregnant client is preparing to undergo a prenatal non-stress test. Which of the following is a reason for performing a non-stress test (NST)? (Select all that apply.) A. Suspected Intrauterine Growth Restriction B. Maternal age between 30 and 35 years C. A history of a full-term birth D. Maternal diabetes E. Multiple gestation
A. Suspected Intrauterine Growth Restriction D. Maternal diabetes E. Multiple gestation A fetal non-stress test (NST) is a non-invasive test that measures the baby's heart rate, movements, and how the fetus reacts to movements while in the womb. The NST is a non-invasive test typically performed after 28 weeks' gestation. It may be ordered for a variety of reasons, including problems with the pregnancy, such as suspected intrauterine growth restriction (IUGR), maternal diabetes, or when the mother is pregnant with more than one baby.
A nurse is caring for a 35-year-old pregnant client who must undergo an amniocentesis. Which of the following are birth defects that are detected by amniocentesis? Select all that apply. A. Tay-Sachs disease B. Cystic fibrosis C. Cleft lip and palate D. Down syndrome E. Tetralogy of Fallot
A. Tay-Sachs disease B. Cystic fibrosis D. Down syndrome Amniocentesis is a prenatal test performed on clients at risk of prenatal complications, to test for genetic anomalies associated with certain birth defects. The test is done by inserting a large needle into the abdomen and withdrawing a small amount of fluid from the amniotic sac surrounding the fetus. The fluid is then analyzed for specific neural tube defects and genetic markers associated with congenital birth defects, including Tay-Sachs disease, cystic fibrosis, and Down syndrome.
A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side B. Palpate the client's uterus C. Administer oxygen to the client D. Increase the client's IV fluids
A. Turn the client onto her left side When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse should turn the client onto her left side since late decelerations indicate uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.
A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression
A. Uteroplacental insufficiency A late deceleration in the FHR is a non-reassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.
A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts
B. 3+ deep tendon reflexes Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider.
A nurse is caring for a client with pre-eclampsia who has a prescription for infusion of magnesium sulfate. Which of the following actions will be implemented by the nurse? (Select all that apply.) A. Dilute IV solutions to <10% B. Monitor urine output C. Assess deep tendon reflexes D. Monitor pupillary response E. Monitor oxygen saturation continuously
B. Monitor urine output C. Assess deep tendon reflexes Intravenous magnesium is used in the management of eclampsia and pre-eclampsia in pregnant clients, as well as for those cardiac arrhythmias, those with severe exacerbations of asthma, and critically ill clients with magnesium depletion from long-term diuretic therapy. It is contraindicated in clients with hyperkalemia, hypermagnesemia, and myasthenia gravis. Nursing assessments during a magnesium infusion include blood pressure and pulse every 10-15 minutes, respiratory rate, deep tendon reflexes, and urine output, particularly for clients with impaired renal function. IV solutions should be diluted to 20% or less. Cardiac monitoring is required during magnesium administration at a rate of >20 mEq/5 hours. An early sign of magnesium toxicity is a loss of deep tendon reflexes, decreased muscle strength, and respiratory depression. The patellar reflex disappears before onset of respiratory depression.
A nurse is assisting with the care of a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis
B. Place the client in a left lateral position The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation.
A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis
B. Place the client in a left lateral position The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation.
A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures
B. Proteinuria The nurse should expect a client with preeclampsia to have proteinuria and impaired kidney function.
A nurse is administering magnesium sulfate IV at 2 g per hr to a client who is pregnant and is experiencing preeclampsia with severe features. Which of the following findings indicates to the nurse that it is safe to continue to administer the medication? A. Diminished deep-tendon reflexes B. Respiratory rate of 16/min C. Urine output of 50 mL in 4 hr D. Increased epigastric pain
B. Respiratory rate of 16/min The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Bradypnea is a clinical manifestation of magnesium toxicity. Therefore, based on this finding, it is safe for the nurse to continue administering the medication.
A client treated with bumetanide (Bumex) has a prescription for magnesium after laboratory studies revealed Mg 0.8 mEq/L. The nurse knows that IV magnesium is used to treat which of the following rhythms? A. Third-degree heart block B. Torsades de pointes C. Multifocal atrial tachycardia D. Atrial fibrillation
B. Torsades de pointes Loop diuretics, including furosemide and bumetanide, affect the balance of sodium, potassium, and chloride in the kidney. They can cause a decrease in the resorption of sodium and chloride, leading to hypokalemia (low potassium) and hypomagnesemia. Hypomagnesemia refers to a serum concentration of magnesium <1.8 mEq/L. Hypomagnesemia and hypokalemia are associated with torsades de pointes, which refers to a specific form of polymorphic ventricular tachycardia that is characterized by rapid, irregular QRS complexes twisting around the ECG baseline. Torsades de pointes is associated with a prolonged QT interval. Since hypomagnesemia can prolong the QT interval, cardiac monitoring may be necessary in clients with profound hypomagnesemia. Torsades de pointes may progress quickly to ventricular fibrillation and death. Treatment is with IV magnesium sulfate.
A nurse has been assigned to care for a pregnant client who has been diagnosed with HELLP syndrome. Which of the following nursing interventions is most important when caring for this client? A. Palpate the abdomen every 4 hours to check for masses or bleeding B. Increase IV fluids to avoid hypotension and shock C. Administer magnesium sulfate as ordered D. Keep the client in a supine position with the legs elevated
C. Administer magnesium sulfate as ordered HELLP syndrome is a severe form of preeclampsia. It most commonly occurs in the third trimester, but can develop earlier in the pregnancy or in the first 48 hours postpartum. Preeclampsia is characterized by new onset hypertension and proteinuria. HELLP resolves with delivery, which is indicated in clients who have preeclampsia and HELLP with a platelet count < 100,000/µL; if the client has progressive deterioration in hepatic or renal function; persistent and severe headaches, visual changes, epigastric pain, nausea, or vomiting; gestational age of 38 weeks; suspected placental abruption; severe fetal growth restriction; oligohydramnios; or nonreassuring fetal stress test. Magnesium sulfate is provided to reduce the risk of seizures, which occur with eclampsia. It may lower blood pressure slightly. Labetalol may be given to reduce blood pressure.
A nurse is caring for a G1P0 female client who is at 37 weeks' gestation. The healthcare provider should be called immediately for which of the following findings during the assessment? A. Low back pain B. Blood pressure 130/80 mmHg C. Severe headache with blurred vision D. Weight gain of 2 lbs since the last visit 5 days earlier
C. Severe headache with blurred vision Preeclampsia is a leading cause of maternal morbidity and mortality. It is characterized by onset of hypertension (blood pressure >140 mm Hg systolic or >90 mm Hg diastolic) after the 20th week of gestation in a woman with previously normal blood pressure, accompanied by proteinuria or new onset of one of the following: low platelet count, renal insufficiency, liver dysfunction, pulmonary edema, or neurological symptoms. Urine protein is 0.3 g or more in a 24-hour urine specimen or a 1+ dipstick reading for protein. Preeclampsia can lead to stroke, acute renal failure, pulmonary edema, DIC, and fetal or maternal death. It may progress to eclampsia, which is characterized by seizures. Risk factors include a prior history of preeclampsia, pregestational diabetes mellitus,advanced maternal age, multifetal gestation, obesity, chronic kidney disease, and lupus. Platelets, urine and serum protein, serum creatinine, weight, and blood pressure should be monitored carefully in the last trimester of pregnancy in women at high risk of preeclampsia. The only option for reversal of preeclampsia is delivery, but in clients who are at 36 weeks' gestation or less, pharmacologic treatment may include antihypertensive medication and magnesium sulfate for seizure prophylaxis. Nursing interventions include accurate blood pressure measurement, dietary guidance to target a healthy body weight; providing client education about warning signs of preeclampsia; and monitoring weight gain that may indicate fluid imbalance and edema.
A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider? A. Deep tendon reflexes 2+ B. Blood pressure 150/96 mmHg C. Urinary output 20 mL/hr D. Respiratory rate 16/min
C. Urinary output 20 mL/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate reduced renal perfusion secondary to a worsening of the client's pre-eclampsia.
A nurse is caring for a client who has preeclampsia and is receiving intravenous magnesium sulfate for the prevention of seizures. Which of the following findings should the nurse report to the provider? A. Positive patellar reflex B. Magnesium level of 4 mEq/L C. Urinary output of 80 mL every 4 hr D. Respiratory rate 14/min
C. Urinary output of 80 mL every 4 hr A urinary output of 80 mL every 4 hr is outside the expected reference range of at least 100 mL every 4 hr. The nurse should report this finding to the provider.
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum
C. Vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly on the client's right side. Based on the presentation of the fetus, the position is vertex.
Which of the following pregnant women will most likely have a screening amniocentesis: A. A 22-year-old client who is at 12 weeks' gestation and is expecting triplets B. A 22-year-old client who is at 4 weeks' gestation C. A 36-year-old woman at 4 weeks' gestation D. A 36-year-old woman at 16 weeks' gestation
D. A 36-year-old woman at 16 weeks' gestation The 36-year-old woman at 16 weeks of gestation is the most likely client to have a screening amniocentesis. Amniocentesis screening is highly accurate for several birth defects such as Down's syndrome, sickle cell disease, cystic fibrosis, muscular dystrophy, and Tay-Sachs disease. Although there are some risks associated with this invasive procedure, it is recommended that pregnant women over the age of 35, those with an abnormal ultrasound, a prior delivery of a child with a birth defect, and/or a family history of birth defects are screened using amniocentesis at about 15 to 18 weeks of gestation.
While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methyl-prostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonrebreather face mask
D. Apply oxygen at 10 L/min via nonrebreather face mask Late decelerations are caused by uteroplacental insufficiency and require intervention to increase oxygen flow to the fetus. Administering oxygen to the client will increase the amount of oxygen available to the fetus.
A nurse is caring for a client who is receiving a magnesium sulfate IV infusion and exhibiting manifestations of magnesium toxicity. Which of the following medications should the nurse expect to administer? A. Nifedipine B. Pyridoxine C. Protamine sulfate D. Calcium gluconate
D. Calcium gluconate Calcium gluconate or calcium chloride is used to treat magnesium sulfate toxicity. It acts to increase the transmission of nerve impulses and contractions of cardiac, skeletal, and smooth muscle.
A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions
D. Implement seizure precautions Clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction equipment are readily available.
