Conditions Nclex questions

Chapter 12: High Risk Perinatal Care- Gestational

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NCM 10

50 terms lilp The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions?

• "I will not experience mood swings since I was only at

10 weeks of gestation."

• "I will avoid sexual intercourse for 6 weeks and

pregnancy for 6 months."

• "I should eat foods that are high in iron and protein to

help my body heal."

• "I should expect the bleeding to be heavy and bright

red for at least 1 week."

• "I should eat foods that are high in iron and protein to help my body heal."

Rationale:

After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider.A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes

concerned after assessment when the woman exhibits:

• a sleepy, sedated affect.
• a respiratory rate of 10 breaths/min.
• deep tendon reflexes of 2+.
• absent ankle clonus.
• a respiratory rate of 10 breaths/min.

Rationale:

Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.

A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is

considered successful if:

• blood pressure is reduced to prepregnant baseline.
• seizures do not occur.
• deep tendon reflexes become hypotonic.
• diuresis reduces fluid retention.
• seizures do not occur.

Rationale:

A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following

findings: temperature 37.1° C, pulse rate 96 beats/min,

respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus.

The nurse calls the physician, anticipating an order for:

• hydralazine.
• magnesium sulfate bolus .
• diazepam.
• calcium gluconate.
• hydralazine.

Rationale:

Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.The most prevalent clinical manifestation of abruptio

placentae (as opposed to placenta previa) is:

• bleeding.
• intense abdominal pain.
• uterine activity.
• cramping.
• intense abdominal pain.

Rationale:

Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae.Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions.A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a

tense, painful abdomen. The nurse suspects the onset of:

• eclamptic seizure.
• rupture of the uterus.
• placenta previa.
• placental abruption.
• placental abruption.

Rationale:

Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

• Administration of blood
• Preparation of the woman for invasive hemodynamic

monitoring

• Restriction of intravascular fluids
• Administration of steroids

(A) Administration of blood

Rationale:

Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because this can contribute to more areas of bleeding. Management of DIC includes volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion?

• Prepare the woman for a dilation and curettage (D&C).
• Place the woman on bed rest for at least 1 week and

reevaluate.

• Prepare the woman for an ultrasound and blood work.
• Comfort the woman by telling her that if she loses this

baby, she may attempt to get pregnant again in 1 month.

• Prepare the woman for an ultrasound and blood work.

Rationale:

D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is

at the greatest risk for:

• hemorrhage.
• infection.
• urinary retention.
• thrombophlebitis.
• hemorrhage.

Rationale:

Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta.The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe?(Select all that apply.)

• Decreased urinary output and irritability
• Transient headache and +1 proteinuria
• Ankle clonus and epigastric pain
• Platelet count of less than 100,000/mm3 and visual

problems

• Seizure activity and hypotension
• Decreased urinary output and irritability
• Ankle clonus and epigastric pain
• Platelet count of less than 100,000/mm3 and visual problems

Rationale:

Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.The emergency department nurse is assessing a pregnant trauma victim who just arrived at the hospital. What are the nurse's MOST appropriate actions? (Select all that apply.)

• Place the patient in a supine position.
• Assess for point of maximal impulse at fourth

intercostal space.

• Collect urine for urinalysis and culture.
• Frequent vital sign monitoring.
• Assist with ambulation to decrease risk of thrombosis.
• Assess for point of maximal impulse at fourth intercostal space.
• Collect urine for urinalysis and culture.
• Frequent vital sign monitoring.

Rationale:

Passive regurgitation may occur if patient is supine, leading to high risk for aspiration. Placental perfusion is decreased when the patient is in a supine position as well. The heart is displaced upward and to the left in pregnant patients. During pregnancy, there is dilation of the ureters and urethra, and the bladder is displaced forward placing the pregnant trauma patient at higher risk for urinary stasis, infection, and bladder trauma. The trauma patient can suffer blood loss and other complications, necessitating frequent monitoring of vital signs.While the pregnant patient is at risk for thrombus formation, the patient must be cleared by the health care provider before ambulating. The pregnant trauma patient is at higher risk for pelvic fracture, and therefore this condition must be ruled out first as well.

A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She is diagnosed with hyperemesis gravidarum.The nurse should include which information when teaching about diet for hyperemesis? (Select all that apply.)

• Eat three larger meals a day.
• Eat a high-protein snack at bedtime.
• Ice cream may stay down better than other foods.
• Avoid ginger tea or sweet drinks.
• Eat what sounds good to you even if your meals are

not well-balanced.

• Eat a high-protein snack at bedtime.
• Ice cream may stay down better than other foods.
• Eat what sounds good to you even if your meals are not well-balanced.

Rationale:

The diet for hyperemesis includes:

• Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids and alternate every 2 to 3 hours.• Eat a high-protein snack at bedtime.• Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature.• In general eat what sounds good to you rather than trying to balance your meals.• Follow the salty and sweet approach; even so-called junk foods are okay.• Eat protein after sweets.• Dairy products may stay down more easily than other foods.• If you vomit even when your stomach is empty, try sucking on a Popsicle.• Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste.• Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon.• Drink liquids from a cup with a lid.