Chapter 19 PrepU

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Ch 19: Nursing Manage of Pregnanc...

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Chapter 19: Nursing Management of...

65 terms shawna421Preview Ricci C 30 terms zha A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

• Premature separation of the placenta
• Placenta previa obstructing the cervix
• Preterm labor that was undiagnosed
• Possible fetal death or injury
• Premature separation of the placenta

Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red 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 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?

• "A cervical cap is placed so no amniotic fluid can

escape."

• "The cervix is glued shut so no amniotic fluid can

escape."

• "Purse-string sutures are placed in the cervix to

prevent it from dilating."

• "Staples are put in the cervix to prevent it from

dilating."

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

The cerclage, or purse string suture, is inserted into the cervix to prevent preterm cervical dilation (dilatation) and pregnancy loss. Staples, glue, or a cervical cap will not prevent the cervix from dilating.

What would be the physiologic basis for a placenta previa?

• low placental implantation
• a loose placental implantation
• a uterus with a midseptum
• a placenta with multiple lobes
• 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.

• leukocytosis
• hemolysis
• elevated liver enzymes
• hyperthermia
• low platelet count
• hemolysis
• elevated liver enzymes
• low platelet count

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.A nurse is caring for a client who just experienced a spontaneous abortion (miscarriage) in the first trimester.When asked by the client why this happened, which is the best response from the nurse?

• abnormal fetal development
• lack of sufficient progesterone produced by the

corpus luteum

• rejection of the embryo through an immune response
• implantation abnormality
• abnormal fetal development

The most frequent cause of spontaneous abortion (miscarriage) in the first trimester of pregnancy is abnormal fetal development, due either to a teratogenic factor or to a chromosomal aberration. In other miscarriages, immunologic factors may be present or rejection of the embryo through an immune response may occur. Another common cause of early miscarriage involves implantation abnormalities. Miscarriage may also occur if the corpus luteum on the ovary fails to produce enough progesterone to maintain the decidua basalis.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
• serum magnesium level of 6.5 mEq/L
• seizures
• elevated liver enzymes
• diminished reflexes

Diminished or absent reflexes occur when a client develops magnesium toxicity.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 woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)?

• Fetus is in a breech position
• Onset of vaginal bleeding was sudden and painful
• Sonogram shows the placenta covering the cervical os
• Uterus is soft between contractions
• Onset of vaginal bleeding was sudden and painful

Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.

A pregnant client at 8 weeks' gestation comes to the facility for vaginal bleeding. Assessment reveals that the client has experienced an incomplete spontaneous abortion (miscarriage) for which suction curettage is planned. While preparing the client for the procedure, the nurse would closely monitor for which possible complication?

• HELLP syndrome
• gestational hypertension
• hemorrhage
• isoimmunization
• hemorrhage

With an incomplete miscarriage, there is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively under this condition. Gestational hypertension or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) are not associated with an incomplete miscarriage. It would be important to determine the client's Rh type because the blood type of the conceptus is unknown.Therefore, all clients with Rh-negative blood should receive Rh (D antigen) immune globulin (RhIG) to prevent the buildup of antibodies in the event the conceptus was Rh-positive to prevent isoimmunization in future pregnancies.A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first?

• Notify the health care provider.
• Administer oxygen to the client.
• Reposition the client to left side.
• Increase the rate of IV fluids.
• Reposition the client to left side.

The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus. After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby.The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor?

• Chromosomal defects in the fetus
• Faulty implantation
• Exposure to chemicals or radiation
• Advanced maternal age
• Chromosomal defects in the fetus

Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.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?

• low platelet count
• hemolysis
• elevated lipoproteins
• liver enzyme elevation
• elevated lipoproteins

The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.

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

• stimulate maternal D immune antigens.
• promote maternal D antibody formation.
• prevent maternal D antibody formation.
• prevent fetal Rh blood formation.
• prevent maternal D antibody formation.

Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.A nursing instructor identifies which factor as increasing the chances of infection when coupled with prolonged labor?

• maternal age
• multiple births
• number of previous pregnancies
• premature rupture of membranes
• premature rupture of membranes

The risk for infection increases during prolonged labor particularly in association with premature rupture of membranes. The other options do not increase the risk of infection during labor.A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?

• painless bright red vaginal bleeding
• "knife-like" abdominal pain with vaginal bleeding
• generalized vasospasm
• increased fetal movement
• "knife-like" abdominal pain with vaginal bleeding

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 placentae.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?

• Administer oxygen to the client.
• Obtain a surgical consent from the client.
• Assess the client's vital signs.
• Provide emotional support to the client and significant

other.

• 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 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?

• ability to sleep
• respiratory rate
• hemoglobin
• urine protein
• respiratory rate

A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). 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.