Ricci, Kyle & Carman: Maternity and Pediatric Nursing, Second Edition: Chapter 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications: PrepU

A 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response?

"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy." Because of the risk of choriocarcinoma, the woman receives extensive treatment. Therapy includes baseline chest X-ray to detect lung metastasis physical exam including pelvic exam. Serum B-hCG levels weekly until negative results are obtained three consecutive times, then monthly for 6 to 12 months. The woman is cautioned to avoid pregnancy during this time because the increasing B-hCG levels associated with pregnancy would cause confusion as to whether cancer had developed. If after a year B-hCG seruim titers are within normal levels, a normal pregnancy can be achieved.

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?

"Come to the health facility with any vaginal material passed." This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so it can be assessed for this.

Which is the best question the nurse can ask a woman who is leaving the hospital after experiencing a complete spontaneous abortion?

"Do you have someone to talk to, or may I give you the names and numbers for some possible grief counselors?" When a woman has a spontaneous abortion one important consideration is the emotional needs of the woman once she is home. She may not want to talk about the loss for a period of time, but the nurse needs to determine her support system for the future. Asking the woman if she is "going to try again" is an inappropriate question for the nurse to ask and diminishes the experience of having a spontaneous abortion. Giving the woman statistical information on spontaneous abortions is not appropriate when this client needs support and caring concern. Offering to give the client resources to aid in smoking cessation is not addressed in the scenario, so this is an inappropriate response.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placenta and placenta previa. Which statement should the nurse include in the teaching?

"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placenta is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor." Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless bright red bleeding in the third trimester. Abruptio placenta is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor.

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." The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placenta.

A client experiences a threatened abortion. She is concerned about losing the pregnancy and asks what activity level she should maintain. What is the most appropriate response from the nurse?

"Restrict your physical activity to moderate bedrest." With a threatened abortion, moderate bedrest and supportive care are recommended. Regular physical activity may increase the chances of miscarriage. Strict bedrest is not necessary. Activity restrictions are part of standard medical management.

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." Abortion is a medical term for any interruption of a pregnancy before a fetus is viable, but it is better to speak of these early pregnancy losses as spontaneous abortions to avoid confusion with intentional terminations of pregnancies. The other responses are correct, but they do not provide the client with the most complete and reassuring answer.

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 suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

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. With severe preeclampsia, most women are hospitalized so that bed rest can be enforced and a woman can be observed more closely than she can be on home care. The nurse should darken the room if possible because a bright light can also trigger seizures. The other interventions listed pertain to a client who has experienced a seizure and has thus progressed to eclampsia.

A pregnant client with hyperemesis gravidarum needs advice on how to minimize nausea and vomiting. Which instruction should the nurse give this client?

Eat small, frequent meals throughout the day. The nurse should instruct the client with hyperemesis gravidarum to eat small, frequent meals throughout the day to minimize nausea and vomiting. The nurse should also instruct the client to avoid lying down or reclining for at least 2 hours after eating and to increase the intake of carbonated beverages. The nurse should instruct the client to try foods that settle the stomach such as dry crackers, toast, or soda.

Spontaneous miscarriage occurs in 5% to 10% of all pregnancies.

False Spontaneous miscarriage occurs in 15% to 20% of all pregnancies and arises from natural causes.

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. The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

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. A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending abortion. Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock.

A 25-week-gestation client presents with a blood pressure of 142/90, pulse 78, no edema, and urine negative for protein. What would the nurse do next?

Notify the healthcare provider The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The healthcare provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.

A client is 20 weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?

The client has pink vaginal discharge and pelvic pressure. Cervical dilatation usually occurs painlessly, and often the first symptom is pink vaginal discharge or increased pelvic pressure, which then is followed by rupture of membranes and discharge of the amniotic fluid. The other answers are nonthreatening signs and symptoms.

In returning to the hospital floor after a weekend off, the nurse takes over care of a pregnant client who is resting in a darkened room. The client is receiving betamethasone and magnesium sulfate. What could the nurse deduce from those findings?

The client is suffering from severe preeclampsia, and the care team is attempting to prevent advancement of the disorder to eclampsia; they are attempting to help the baby's lungs mature quickly so that they can have the baby be born as soon as possible. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of the betamethasone is to try and hasten the maturity of the fetus' lungs for birth. This woman is in advanced preeclampsia and must be monitored for progression to eclampsia. The scenario described does not indicate a client with hypertension who may be discharged home once the condition is under control. A woman in eclampsia would either be seizing or comatose, not resting in a quiet room. Symptoms of mild preeclampsia are limited to slightly elevated blood pressure and small amounts of protein in the urine. Betamethasone may be indicated at this time.

Vaginal bleeding during pregnancy is always a deviation from the normal.

True Vaginal bleeding during pregnancy is always a deviation from the normal, is always potentially serious, may occur at any point during pregnancy, and is always frightening. It must always be carefully investigated because it can impair both the outcome of the pregnancy and the woman's life or health.

The nurse is transcribing messages from the answering service. Which phone message should the nurse return first?

a 35-year-old, 21-week G3P2 client with blood pressure of 160/110 mm Hg, blurred vision, and whose last blood pressure was 143/99 mm Hg and urine dipstick showed a +2 proteinuria The nurse should call the at-risk 35-year-old client first. She is 21 weeks and has symptoms (blurred vision) of preeclampsia. She also had an increase of protein in her urine (2+) and a 15% increase in her BP. The nurse will need more information to determine if the 38-week client may be in the early stages of labor, and if the 31-week client with flank pain has a kidney infection. The client with malaise and rhinitis will need to talk to the nurse last to find out what over-the-counter medication she is able to take.

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?

a client who had a myomectomy to remove fibroids A previous myomectomy to remove fibroids can be associated with the cause of placenta previa. Risk factors also include advanced maternal age (greater than 30 years old). A structurally defective cervix cannot be associated with the cause of placenta previa. However, it can be associated with the cause of cervical insufficiency. Alcohol ingestion is not a risk factor for developing placenta previa but is associated with abruption placenta.

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. 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.

Rho(D) immune globulin will be prescribed for an Rh negative mother undergoing which test?

amniocentesis Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.

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 When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital.

A client is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 centimeters, cervical insufficiency, and a visible amniotic sac at the cervical opening. What is the primary goal for this client at this point?

bed rest to maintain pregnancy as long as possible At 22 weeks' gestation, the fetus is not viable. The woman would be placed on bed rest, total, with every attempt made to halt any further progression of dilatation as long as possible. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.

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. Fetal nonimmune hydrops occurs in the infection of pregnant clients with parvovirus. Postterm birth, maternal hypotension, and fetal nonimmune hydrops are not seen as complications of multiple pregnancy.

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 Diminished or absent reflexes occur when a client develops magnesium toxicity, serum levels greater than 8.0 mEq/L. Elevated liver enzymes are unrelated to magnesium toxicity and may indicate the development of HELLP syndrome. The onset of seizure activity indicates eclampsia. A serum magnesium level of 6.5 mEq/L would fall within the therapeutic range of 4 to 7 mEq/L.

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 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 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 meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

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

gestational hypertension Hypertensive disorders represent the most common complication of pregnancy. Gestational hypertension is elevated blood pressure without proteinuria, other signs of preeclampsia, or preexisting hypertension. Abruptio placenta (separation of the placenta from the uterine wall), placenta previa (placenta covering the cervical os), and preeclampsia are high-risk, potentially life-threatening conditions for the fetus and mother during labor and birth.

A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination there is an elevated hCG level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?

gestational trophoblastic disease The client is most likely experiencing gestational trophoblastic disease or a molar pregnancy. In gestational trophoblastic disease or molar pregnancy, there is an abnormal proliferation and eventual degeneration of the trophoblastic villi. The signs and symptoms of molar pregnancy include brownish vaginal bleeding, elevated hCG levels, discrepancy between the uterine size and the gestational age, and absent fetal heart sounds. Abruption of placenta is characterized by premature separation of the placenta. Ectopic pregnancy is a condition where there is implantation of the blastocyst outside the uterus. In placenta previa the placental attachment is at the lower uterine segment.

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

immediate surgery Ectopic pregnancy means an embryo has implanted outside the uterus, usually in the fallopian tube. Surgery is usually necessary to remove the growing structure before the tube ruptures or to repair the tube if rupture has occurred already.

What would be the physiologic basis for a placenta previa?

low placental implantation The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

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

low platelet count elevated liver enzymes hemolysis The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.

The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions would the nurse most likely include? Select all that apply.

maintaining NPO status for the first day or two administering antiemetic agents obtaining baseline blood electrolyte levels monitoring intake and output When hospitalization is necessary, oral food and fluids are withheld to allow the gut to rest. Antiemetic agents are ordered to help control nausea and vomiting. The woman is likely to be dehydrated, so the nurse would obtain baseline blood electrolyte levels and administer intravenous fluid and electrolyte replacement therapy as indicated. Once the nausea and vomiting subside, oral food and fluids are gradually reintroduced. Total parenteral nutrition or a feeding tube is used to prevent malnutrition only if the client does not improve with these interventions.

Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy?

methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition?

mild preeclampsia A woman is said to have gestational hypertension when she develops an elevated blood pressure (140/90 mm Hg) but has no proteinuria or edema. If a seizure from gestational hypertension occurs, a woman has eclampsia, but any status above gestational hypertension and below a point of seizures is preeclampsia. A woman is said to be mildly preeclamptic when she has proteinuria and a blood pressure rise to 140/90 mm Hg, taken on two occasions at least 6 hours apart. A woman has passed from mild to severe preeclampsia when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest (the position in which blood pressure is lowest) or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are also present. A woman has passed into eclampsia when cerebral edema is so acute a grand-mal seizure (tonic-clonic) or coma has occurred.

A pregnant client with severe preeclampsia has developed HELLP syndrome. In addition to the observations necessary for preeclampsia, what other nursing intervention is critical for this client?

observation for bleeding Because of the low platelet count associated with this condition, women with HELLP syndrome need extremely close observation for bleeding, in addition to the observations necessary for preeclampsia. Maintaining a patent airway is a critical intervention needed for a client with eclampsia while she is having a seizure. Administration of a tocolytic would be appropriate for halting labor. Monitoring for infection is not a priority intervention in this situation.

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment would be most important prior to administering a new dose?

patellar reflex A symptom of magnesium sulfate toxicity is loss of deep tendon reflexes. Assessing for one of these before administration is assurance the drug administration will be safe.

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 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 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time?

pregnancy loss The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for pregnancy loss. Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What is the most likely cause of these symptoms?

premature separation of the placenta Premature separation of the placenta begins with sharp fundal pain, usually followed by vaginal bleeding. Placenta previa usually produces painless bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain. It is usually painless.

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 Even with precautions, in most instances of hydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are not as big of concerns as preterm birth, in this situation.

A client for has an Rh-negative blood type. Following the birth of the client's infant, the nurse administers her Rho(D)immune globulin. The purpose of this is to:

prevent maternal D antibody formation. Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies.

A client is admitted to labor and birth for management of severe preeclampsia. An IV infusion of magnesium sulfate is started. What is the primary goal for magnesium sulfate therapy?

prevent maternal seizures The primary therapy goal for any preeclamptic client is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as its primary goal a decrease in blood pressure, a decrease in protein in the urine, nor the reversal of edema.

The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every two hours. Why would the nurse do this?

pulmonary edema In the hospital, monitor blood pressure at least every four hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every two hours. Adventitious sounds may indicate developing pulmonary edema.

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3° F (36.2° C), pulse 88 beats/min, respirations 10 breaths/min, blood pressure 148/110 mm Hg. What other priority physical assessment by the nurse should be implemented to assess for potential toxicity?

reflexes Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.

A client with preeclampsia is receiving magnesium sulfate. Which nursing assessment should be ongoing while the medication is being administered?

respiratory rate The level of magnesium in therapeutic range is 4 to 8 mg/dL. If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment

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 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.

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

slight vaginal bleeding Slight vaginal bleeding early in pregnancy, no cervical dilation, and a closed cervical os are associated with a threatened abortion. Strong abdominal cramping is associated with an inevitable abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion.

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 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 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 Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. This is why it is important for any woman who begins to miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of clear fluid-filled cysts changes the diagnosis from a simple miscarriage to gestational trophoblastic disease. The client is not instructed to bring in passed tissue to determine whether infection is present or the fetus is viable or to determine the stage of development of the fetus.

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?

twin-to-twin transfusion syndrome (TTTS) When twins share a placenta, a serious condition called twin-to-twin transfusion syndrome (TTTS) can occur.

A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?

use of IUD for contraception Use of an IUD with progesterone has a known increased risk for development of ectopic pregnancies. The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple elective abortions. Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. Hormonal factors may play a role because tubal pregnancy occurs more frequently in women who take fertility drugs or who use progesterone intrauterine contraceptive devices (IUDs). A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.