Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication

Chapter 21: Nursing Care of a Family Experiencing a

Sudden Pregnancy Complication Leave the first rating Students also studied Terms in this set (26) Science MedicineObstetrics Save

Chapter 25: Nursing Care of a Famil...

27 terms johnmarkobina2 Preview

Chapter 24: Nursing Care of a Famil...

26 terms nikki4922Preview

Chapter 26: Nursing Care of a Famil...

43 terms johnmarkobina2 Preview Ch 23 N 54 terms riss A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

• performing a vaginal examination to assess the extent

of bleeding

• helping the woman remain ambulatory to reduce

bleeding

• assessing fetal heart tones by use of an external

monitor

• assessing uterine contractions by an internal pressure

gauge

Answer: C

Rationale: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.What would be the physiologic basis for a placenta previa?

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

Answer: B

Rationale: The cause of placenta previa is usually unknown, but for some reason

the placenta is implanted low instead of high on the uterus.

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?

• "Maintain bed rest, and count the number of perineal

pads used."

• "Come to the health care facility if uterine contractions

begin."

• "Continue normal activity, but take the pulse every

hour."

• "Come to the health facility with any vaginal material

passed."

Answer: D

Rationale: 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 the material can be assessed for this.A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's

best response would be that:

• no more than three children is recommended.
• as long as she receives Rho(D) immune globulin, there

is no limit.

• only her next child will be affected.
• she will have to ask her primary care provider.

Answer: B

Rationale: Because Rho(D) immune globulin supplies passive antibodies, it

prevents the woman from forming antibodies. Without antibodies that could affect the fetus, the woman could have as many children as she wants.A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical?

• increased perspiration
• weight loss
• susceptibility to infection
• blood pressure elevation

Answer: D

Rationale: The symptom of gestational hypertension is blood pressure elevation

(140/90 mm Hg) identified after 20 weeks' gestation without proteinuria.A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The clientstates, "It started all of a sudden and now it seems to have stopped." Placenta previa is suspected. Which action should the nurse implement immediately for this client?

• Determine fetal heart sounds using an external

monitor.

• Prepare the client for an immediate cesarean birth.
• Assist with insertion of internal monitoring to assess

uterine pressure.

• Prepare the client for a pelvic examination to assess

rupture of membranes.

Answer: A

Rationale: For placenta previa, the nurse should attach external monitoring

equipment to record fetal heart sounds and uterine contractions. Internal monitoring is contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both the pregnant client and fetus. The decision to birth the fetus depends on the point at which a diagnosis of placenta previa is made and the age of the gestation. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the fetal heart rate to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, pregnant client vital signs are good, and the fetus is not yet 36 weeks of age, a client is usually managed by expectant watching.

The nurse is preparing an education session on the 2030 National Health Goals to prevent complications of pregnancy. What should the nurse include as the best preventive measure to eliminate complications of pregnancy?

• Encourage all pregnant clients to have prenatal care.
• Suggest all pregnant clients keep weight gain to a

minimum.

• Recommend all pregnant clients engage in exercise

most days of the week.

• Counsel all pregnant clients to select low-fat dairy

products rich in calcium.

Answer: A

Rationale: Encouraging all women to come for prenatal care is the best preventive measure for eliminating complications of pregnancy. Weight gain, exercise, and calcium intake are not identified as specific measures to prevent complications of pregnancy.The nurse is concerned that a pregnant client is experiencing abruptio placentae. What did the nurse assess in this client?

• increased blood pressure and oliguria
• pain in a lower quadrant and increased pulse rate
• painless vaginal bleeding and a fall in blood pressure
• sharp fundal pain and discomfort between

contractions

Answer: D

Rationale: Abruptio placentae is characterized by a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. Manifestations of abruptio placentae do not include increased blood pressure, oliguria, pain in the lower quadrant, increased pule rate, painless vaginal bleeding, or a fall in blood pressure.A client who is 16 weeks' pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the client to do at this time?

• Begin immediate bed rest.
• Count the number of perineal pads that are saturated

with blood.

• Continue with normal daily activity and monitor pulse

rate every hour.

• Seek immediate medical attention and bring the

expressed vaginal material.

Answer: D

Rationale: Gestational trophoblastic disease is abnormal proliferation and then

degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. At approximately week 16 of pregnancy, vaginal bleeding will begin as spotting of dark-brown blood accompanied by discharge of the clear fluid- filled vesicles. The pregnant client who begins to miscarry at home needs to bring any clots or tissue passed to the hospital because the presence of clear fluid- filled cysts identifies gestational trophoblastic disease. The client needs to seek immediate medical attention and not stay at home on bed rest, count perineal pads, or continue with normal activity and count pulse rates every hour.The nurse is reviewing the plan of care for a pregnant client experiencing a threatened miscarriage. Which outcome would be appropriate for this client?

• Bed rest is maintained until all bleeding stops.
• Less than one perineal pad is saturated per hour.
• Bleeding spontaneously stops within 24 to 48 hours.
• Normal coitus is resumed 1 week after the episode.

Answer: C

Rationale: For a threatened miscarriage, an outcome for care would be that all

bleeding would spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a perineal pad in 1 hour is an emergency and could indicate an incomplete or complete miscarriage. Normal coitus should be withheld for 2 weeks after a threatened miscarriage.

A pregnant client with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful?

• The client delivers a full-term fetus at 39 weeks'

gestation.

• The client's membranes spontaneously rupture at week

30 of gestation.

• The client experiences minimal vaginal bleeding

throughout the pregnancy.

• The client has reduced shortness of breath and

abdominal pain during the pregnancy.

Answer: A

Rationale: Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation.Spontaneous rupture of the membranes could indicate that the procedure was not successful.Vaginal bleeding could indicate another health problem or that the procedure was not successful. This procedure does not impact the client's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.The nurse is evaluating care provided to a client in the third trimester of pregnancy who has been diagnosed with gestational hypertension. Which finding indicates that treatment has been successful for this client?

• urine protein 0
• increased perspiration
• weight gain of 1 lb/week
• diastolic blood pressure 20 mmHg over normal level

Answer: A

Rationale: Manifestations of gestational hypertension include elevated blood

pressure, edema, and proteinuria. Absence of protein in the urine indicates that treatment has been successful. Increased perspiration is not a manifestation of gestational hypertension. A weight gain of 1 lb/week in the client who is in the third trimester of pregnancy is an indication of ongoing edema. A diastolic blood pressure that is 20 mmHg over normal level is an indication of ongoing hypertension.A pregnant client is being admitted for severe preeclampsia. In which room location should the nurse place this client?

• near the nursery
• next to the elevator
• in a darkened room
• across from the nurse's station

Answer: C

Rationale: With preeclampsia with severe features, most women are hospitalized

so that they can be closely monitored. Visitors are usually restricted to support people such as a partner, father of the child, mother, or older children. Raise bed side rails to help prevent injury if a seizure should occur. The room should be darkened if possible because a bright light can also trigger seizures. However, the room should not be so dark that caregivers need to use a flashlight to make assessments.Sudden noises, such as noises from the nursery, elevator or nurse's station can trigger a seizure in a woman with preeclampsia with severe features.The nurse is monitoring a pregnant client who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do?

• Check the fetal heart rate.
• Measure blood pressure.
• Stop the current infusion.
• Increase the infusion rate.

Answer: C

Rationale: When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time and provide the client with more magnesium sulfate. The infusion rate should not be increased because this could lead to cardiac dysrhythmias and respiratory depression.The nurse is identifying nursing diagnoses for a client with gestational hypertension. Which diagnosis would be the most appropriate for this client?

• risk for injury related to fetal distress
• imbalanced nutrition related to decreased sodium

levels

• ineffective tissue perfusion related to poor heart

contraction

• ineffective tissue perfusion related to vasoconstriction

of blood vessels

Answer: D

Rationale: In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.