Unit 3 (Sem 4) Preeclampsia/HELLP/abruptio placentae
The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history? 1 Cardiac disease 2 Hyperthyroidism 3 Gestational hypertension 4 Cephalopelvic disproportion
Gestational hypertension Rationale: Hypertension during pregnancy leads to vasospasm; this in turn causes the placenta to tear away from the uterine wall (abruptio placentae). Generally cardiac disease does not cause abruptio placentae. Hyperthyroidism may cause an endocrine disturbance in the infant but does not affect blood supply to the uterus. Cephalopelvic disproportion may affect the birth of the fetus but does not affect the placenta.
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death
Gravitate l who has had an intrauterine fetal death Rationale: Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.
A client who has experienced a severe abruptio placentae asks the nurse why there was so much bleeding. What should the nurse consider as the cause of the heavy bleeding before responding in language that the client will understand? 1 Polycythemia 2 Thrombocytopenia 3 Hyperglobulinemia 4 Hypofibrinogenemia
Hypofibrinogenemia Rationale: Clotting defects are common in moderate and severe abruptio placentae because of the loss of fibrinogen caused by copious internal bleeding. An excessive amount of red blood cells is not related to the depletion of fibrinogen. The bleeding with abruptio placentae is caused by depletion of fibrinogen, not thrombocytes (platelets). Excessive globulin in the blood is unrelated to clotting.
A primary healthcare provider prescribes an intravenous infusion of magnesium sulfate for a client with preeclampsia. What baseline assessment is essential before the nurse initiates the infusion? 1 Serum glucose 2 Respiratory rate 3 Body temperature 4 Level of consciousness
Respiratory rate Rationale: Magnesium sulfate toxicity depresses respiration; therefore it is essential to obtain a baseline respiratory rate before initiating therapy. The serum glucose level is unrelated to magnesium sulfate toxicity. Deviations in temperature do not indicate magnesium sulfate toxicity. A decreased level of consciousness may indicate worsening preeclampsia, not magnesium sulfate toxicity
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency cesarean birth because of abruptio placentae and severe fetal compromise. The client received 10 mg of nalbuphine intravenously 30 minutes ago. Because the client is too sedated to sign the consent form, what should the nurse do? 1 Call the client's mother and request a verbal consent. 2 Proceed with the preparation and forgo written consent. 3 Have the surgeon and attending primary healthcare provider sign the consent form. 4 Sign the consent form and have the nurse manager countersign the form.
Have the surgeon and attending primary healthcare provider sign the consent form. Rationale: The data indicate a life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There is not enough time to obtain verbal consent. It is illegal to perform the surgery without a signed consent. Legally a nurse is not allowed to countersign an informed consent unless the client has signed it first.
The nurse knows that when a magnesium sulfate infusion is given to a client with preeclampsia, it can build to a toxic level. Which assessment finding should prompt the nurse to withhold the medication and notify the primary healthcare provider? 1 Respirations of 14 breaths/min 2 Absence of deep tendon reflexes 3 Urine output of 30 mL/hr 4 Blood pressure of 140/100 mm Hg
Absence of deep tendon reflexes Rationale: A side effect of magnesium sulfate is depressed reflex responses; this may indicate toxicity, and intervention is necessary. Respirations of 14 breaths/min is a positive sign that toxicity has not occurred. A respiratory rate of 12 breaths/min or slower is a concern that requires nursing intervention. The amount of urine output is important, because oliguria may signify magnesium toxicity, but 30 mL/hr is within the acceptable range. The blood pressure is expected to increase; this medication is administered to prevent a seizure, not to lower blood pressure.
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the primary healthcare provider if the respiratory rate is slower than 20 breaths/min
1, 3, 4, 5 Rationale: Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/hr must be reported to the primary healthcare provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary healthcare provider
A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What adverse effects indicate that the serum magnesium level may be excessive? Select all that apply.
Absence of the knee jerk reflex Respiratory rate of 11 breaths/min Rationale: An absence of the knee-jerk reflex is a manifestation of hyporeflexia; it is a possible indication of magnesium sulfate toxicity. A respiratory rate of 11 breaths/min is cause for concern; any rate slower than 12 breaths/min is a sign of magnesium sulfate toxicity. A urinary output of 100 mL/hr is adequate; output of less than 30 mL/hr indicates inadequate excretion of magnesium sulfate and the potential for toxicity. The maternal blood pressure is not directly related to magnesium sulfate administration or toxicity; however, decreased blood pressure indicates that the treatment has been effective. A pulse rate of 80 beats/min is an expected pulse rate, not an indicator of toxicity.
Which clinical finding does the nurse expect when assessing a client with abruptio placentae? 1 Flaccid uterus 2 Painless bleeding 3 Boardlike abdomen 4 Bright red bleeding
Boardlike abdomen Rationale: Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.
A client with mild preeclampsia is told that she must remain on bed rest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond? 1 "Let's explore your available current support and opportunities for child care." 2 "Are you worried about how you'll be able to handle this problem?" 3 "You can get a neighbor to help out, and your husband can do the housework in the evening." 4 "You can prepare light meals and the children can go to nursery school a few hours each day."
"Let's explore your available current support and opportunities for child care." Rationale: Asking the client how she plans to manage with getting child care help addresses the problem directly while providing an opportunity for the client to examine her options. The therapeutic regimen includes bed rest and peace of mind; these can best be fulfilled if the children are cared for adequately. Asking whether the client is worried about how she will be able to handle this problem explores feelings but does not include a therapeutic regimen. Stating that the client can get a neighbor to help out and have the husband do the housework in the evening is giving a solution rather than exploring the situation with the client. Complete bed rest has been prescribed, and the suggestion of nursery school for the children assumes that the client is able to afford it.
A client with severe preeclampsia who was admitted to the high-risk unit anxiously asks the nurse, "Will my baby be all right?" How should the nurse respond?
"We'll be monitoring your baby's condition continuously. Would you like to listen to the baby's heartbeat?" Rationale: Explaining to the client that the fetus will be closely monitored and asking whether she would like to hear the heartbeat serves to reassure the client of the fetus's well-being. Stating that there is no way of telling at this time what the outcome will be does not provide the mother with reassurance regarding the fetus's status or whether anything is being done to monitor the fetus. Stating that if the client does what the primary healthcare provider tells her to do everything will progress normally provides false reassurance; following instructions does not guarantee a healthy newborn. Stating that the baby will be all right provides false reassurance, and amniotic fluid makes the umbilical cord less vulnerable but does not protect against other causes of fetal compromise.
A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows fetal bradycardia, and a change is seen in the contour of the client's abdomen. What is the nurse's priority intervention? 1 Checking the client's vital signs 2 Placing the client on her left side 3 Immediately placing an internal scalp electrode on the fetus 4 Alerting others regarding the need for immediate cesarean delivery
Alerting others regarding the need for immediate cesarean delivery Rationale: Another nurse should be asked to notify the operating room staff, primary healthcare provider, anesthesiologist, and neonatal team to prepare. The client's nurse should monitor vital signs, watch for signs of hypotension and tachycardia, insert an indwelling catheter, and stay as calm as possible while explaining to the client that the staff are working together to bring about a safe outcome. The client is exhibiting signs of uterine rupture. An emergency cesarean birth is the priority. Vital signs may be checked immediately after another nurse has been asked to bring the team together. Placing an internal fetal monitor is a poor use of valuable time and requires a prescription from the primary healthcare provider. Client history, fetal bradycardia, and change of abdominal contour indicate uterine rupture.
What is the priority nursing action when caring for a client with disseminated intravascular coagulation? 1 Monitor for Homans sign. 2 Avoid giving intramuscular injections. 3 Take temperatures via the rectal route. 4 Apply sequential compression stockings.
Avoid giving intramuscular injections Rationale: Massive amounts of clots formed in the microcirculation deplete platelets and clotting factors, leading to bleeding; the trauma of an injection may cause excessive bleeding. Monitoring for Homans sign is associated with thrombophlebitis. Taking temperatures via the rectal route could be traumatic and precipitate bleeding. Sequential compression stockings are used to prevent thrombophlebitis.
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
Bleeding at the venipuncture site Rationale: Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
What should the plan of care for a client with a tentative diagnosis of partial abruptio placentae include? 1 Bed rest with sedation 2 Trendelenburg position and hydration 3 Preparation for emergency cesarean birth 4 External fetal monitoring and oxygenation
External fetal monitoring and oxygenation Rationale: Fetal monitoring and oxygen administration should be instituted to protect the fetus. Some placental separation has occurred, and it may progress further. Sedation is contraindicated; it may further stress an already compromised fetus. The Trendelenburg position may shift the heavy uterus against the diaphragm and lead to compromised maternal respiratory function, further depriving the fetus of oxygen. Hydration is not a priority at this time. Further assessment of fetal status and progression of abruption placentae is needed before a cesarean birth is considered.
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply.
Headache Abdominal pain Flu-like symptoms Rationale: Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation and vaginal bleeding are not related to preeclampsia.
While a client is being given intravenous magnesium sulfate therapy for preeclampsia, it is essential for the nurse to monitor the client's deep tendon reflexes. What reason does the nurse give to the client to explain why this is done? 1 Reveals her level of consciousness 2 Reveals the mobility of the extremities 3 Reveals the response to painful stimuli 4 Identifies the potential for respiratory depression
Identifies the potential for respiratory depression Rationale: Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dL. Deep tendon reflexes disappear when the serum level is 10 to 12 mg/dL. The medication is withheld in the absence of deep tendon reflexes. The therapeutic serum level of magnesium sulfate is 5 to 8 mg/dL. Deep tendon reflexes do not reveal a client's level of consciousness, mobility of the extremities, or the response to painful stimuli. Deep tendon reflexes can be associated with muscle strengthening.
A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. What should the nurse assess the client for? 1 Bright-red vaginal bleeding and multiple clots 2 Uterine tenderness and increased fetal activity 3 Cessation of contractions and decreased uterine size 4 Concealed hemorrhage and fetal heart rate accelerations
Uterine tenderness and increased fetal activity Rationale: When the placenta initially separates, the fetus may become hyperactive as a response to acute hypoxia; the uterus is tender because of the accumulation of blood at the abrupted placental site. If bleeding occurs, it is dark red or port wine colored and usually does not clot. The uterus generally enlarges because of an accumulation of blood at the placental site. It is difficult to assess a client for concealed hemorrhage; the fetus must first be assessed for fetal heart tones to determine viability, not for increases or decreases in the heart rate.
A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential? 1 Fundal height 2 Obstetric history 3 Time of the last meal 4 Family history of bleeding disorders
Fundal height Rationale: It is vital that a baseline measurement be obtained, because increasing fundal height may be a sign of concealed hemorrhage. Taking an obstetric history, ascertaining the time of the last meal, and asking about a family history of bleeding disorders are all appropriate assessments; however, none are a priority at this critical time.
A pregnant client is admitted to the high-risk unit with uterine tenderness and some dark-red vaginal bleeding. Abruptio placentae is diagnosed. Which priority assessment should be included with vital signs, skin color, urine output, and fetal heart rate? 1 Fundal height 2 Obstetric history 3 Time of last meal 4 History of bleeding tendencies
Fundal height Rationale: It is vital that a baseline measurement of the height of the fundus be obtained, because increasing size is an indication of concealed hemorrhage; with abruptio placentae, bleeding occurs behind the placenta. Obstetric history, time of the last meal, and history of bleeding tendencies are all appropriate assessment questions; however, none are a priority at this time.
The nurse is performing a physical assessment of a pregnant woman. Which factor in the client's history increases the risk for abruptio placentae? 1 Hydramnios 2 Hypertension 3 Cardiac disease 4 Diabetes mellitus
Hypertension Rationale: Abruptio placentae occurs in about 1% of all pregnancies. The problem is more common in women with hypertension; however the causative factors are not clear. Hydramnios occurs about 10 times more often in pregnancies involving clients with type 1 diabetes. Spontaneous abortion, preterm labor and birth, and intrauterine fetal growth retardation are more common in pregnant clients with heart disease than in those without it. There is not a higher incidence of abruptio placentae in clients with diabetes mellitus; clients with diabetes are more likely to experience preeclampsia or to go into preterm labor if they have diabetes before becoming pregnant, especially if pathologic changes related to diabetes are present.
A client who received intravenous magnesium sulfate for preeclampsia gives birth. What clinical finding in the newborn indicates to the nurse that magnesium sulfate toxicity may have occurred?
Hypotonia Rationale: Hypotonia occurs with magnesium sulfate toxicity because of skeletal and smooth muscle relaxation. Pallor, tremor, and tachycardia are not signs of magnesium sulfate toxicity.
The nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. Which complication associated with a placental abruption should the nurse carefully monitor this client for? 1 Cerebral hemorrhage 2 Pulmonary edema 3 Impending seizures 4 Hypovolemic shock
Hypovolemic Shock Rationale: With abruptio placentae, uterine bleeding can result in massive internal hemorrhage, causing hypovolemic shock. A cerebral hemorrhage may occur with a dangerously high blood pressure; there is no information indicating the presence of a dangerously high blood pressure. Pulmonary edema may occur with severe preeclampsia or heart disease, and seizures are associated with severe preeclampsia; there is no information indicating the presence of these conditions.
A client with abruptio placentae has an emergency cesarean birth. Subsequently the nurse notes bloody urine in the indwelling catheter collection bag. Which impending problem does the nurse suspect? 1 Incisional nick in the bladder 2 Urinary infection from the catheter 3 Uterine relaxation with increased lochia 4 Disseminated intravascular coagulopathy
Incisional nick in the bladder Rationale: During an emergency cesarean birth the urinary bladder may be nicked during attempts to reach the uterus. Bleeding associated with a urinary tract infection is unlikely to develop so soon after a birth. Lochia is expelled from the vagina, not the bladder. With dissociated intravascular coagulopathy there would be bleeding from other sites, such as the incision and the venipuncture site, not just the bladder.
A nurse is monitoring a client with severe preeclampsia who is receiving an infusion of magnesium sulfate. Assessment reveals a pulse rate of 55 beats/min, a respiratory rate of 10 breaths/min, and a flushed face. What are the next nursing actions? 1 Continuing the infusion and notifying the primary healthcare provider 2 Stopping the infusion and starting an infusion of dextrose and water 3 Continuing the infusion and documenting the findings in the clinical record 4 Decreasing the rate of the infusion and obtaining blood for a magnesium level
Stopping the infusion and starting an infusion of dextrose and water Rationale: The client's slow pulse, respirations, and flushed face are signs of magnesium sulfate toxicity. The infusion should be stopped and the intravenous site maintained with an infusion of dextrose 5% in water because an antagonist (calcium gluconate) may be prescribed. Continuing the infusion and notifying the primary healthcare provider is unsafe because continuing the infusion will make the central nervous system (CNS) depression more severe. The primary healthcare provider should be notified after the infusion has been stopped. Continuing the infusion and documenting the findings in the clinical record are unsafe; the client's clinical manifestations indicate a life-threatening condition. It is unsafe to decrease the rate of the infusion because the CNS depression will worsen. Blood for determination of the magnesium level should be obtained, but not before the infusion is stopped.