OB Prep U CH.19 [For EXAM 2]

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 1, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

Reflexes

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

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?

diminished reflexes

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension

A pregnant client at 32 weeks' gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response by the nurse?

"It is best for you to visit a hospital immediately. They can use a nitrazine strip to determine if it is amniotic fluid.

A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

-hemolysis -elevated liver enzymes -low platelet count

A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the priority for this client?

Administer IV NS with vitamins and electrolytes

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?

Bed rest to maintain pregnancy as long as possible

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?

Monitor the client's vital signs and bleeding.

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

assessing the amount and color of the bleeding

A woman is admitted with a diagnosis of ectopic pregnancy. For which procedure should the nurse prepare?

immediate surgery

A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90 mm Hg. Her urine is negative for proteinuria. The nurse recognizes which factor as the potential cause?

gestational hypertension

A client with a history of cervical insufficiency is seen for reports of pink-tinged discharge and pelvic pressure. The primary care provider decides to perform a cervical cerclage. The nurse teaches the client about the procedure. Which client response indicates that the teaching has been effective?

"Purse-string sutures are placed in the cervix to prevent it from dilating."

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?

Ectopic pregnancy

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?

Respiratory rate

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

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?

fetal distress related to hypoxia

When assessing a pregnant woman with vaginal bleeding, the nurse would suspect a threatened abortion based on which finding?

slight vaginal bleeding

A woman in week 16 of her pregnancy calls her primary care provider's office to report that she has experienced abdominal cramping, cervical dilation, vaginal spotting, and the passing of tissue. The nurse instructs the client to bring the passed tissue to the hospital with her. What is the correct rationale for this instruction?

to determine whether gestational trophoblastic disease is present

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

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?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

A 16-year-old client gave birth to a 12 weeks' gestation 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 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."

A student nurse asks the instructor what percentage of clinically recognized pregnancies end in miscarriages during the first trimester. Which response from the nurse is the most accurate?

15% to 20%

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?

Amniocentesis

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.

A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?

Confine the client to bed rest in a darkened room.

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?

Palpate the fundus and check fetal heart rate.

A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated?

Phrenic nerve irritation

A client at 27 weeks' gestation is admitted to the OB unit afer reporting headaches and edema of her hands. Review of the prenatal notes reveals BP consistently above 136/90 mm Hg. The nurse anticipates the health care provider will order magneisum sulfate to accomplish which primary goal?

Prevent maternal seizures

A nurse is conducting a presentation for a group of pregnant women about conditions that can occur during pregnancy and that place the woman at high-risk. When discussing blood incompatibilities, which measure would the nurse explain as most effective in preventing isoimmunization during pregnancy?

Rho(D) immune globulin administration to Rh-negative women

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

diminished reflexes

A woman with a recent incomplete abortion is to receive therapeutic misoprostol. The nurse understands that the rationale for administering this drug is to:

ensure passage of all the products of conception.

A client has been admitted with 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

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 dipstick value of 2+ for protein.

A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

A transvaginal ultrasound

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

A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and alert the RN or health care provider?

Initial BP 100/70 mm Hg; current BP 140/90 mm Hg

A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which measure will be important for the nurse to include in the care plan?

Institute and maintain seizure precautions.

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client?

Keep the suction equipment readily available.

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.

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."

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin?

STIs

A woman in week 35 of her pregnancy 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

A 24-year-old client presents in labor. The nurse notes there is an order to administer RhoGAM after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

prevent maternal D antibody formation.