Maternity Exam SIX.....

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Bra 1) A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what?

• Sodium
• Carbohydrates
• Protein
• Fruits

Answer: C

Explanation

• It is important that the client limit her intake of sodium.
• While it is important that the client have an adequate intake of carbohydrates,

another food group is more important.

• The client who experiences preeclampsia is losing protein.
• It is important that the client have adequate intake of fruits, but another food

group is more important.1) The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?

• Excretion of less than 300 m g of protein in a 24-hour

period

• Platelet count of less than 150,000/m m3
• Urine output of 50 m L per hour
• 12 respirations

Answer: B

Explanation:

• Excretion of more than 300 m g of protein in a 24-hour period is considered

abnormal.

• HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)

complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 150,000/m m3).

• Urine output of a least 30m L/hour is considered normal.
• Respirations of 12 are normal.

1) A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say?

• "Your baby will be fine. We'll start IV, and get this

stopped in no time at all."

• "Your cervix is beginning to dilate. That is a serious

sign. We will continue to monitor you and the baby for now."

• "You are going to miscarry. But you should be relieved

because most miscarriages are the result of abnormalities in the fetus."

• "I really can't say. However, when your physician

comes, I'll ask her to talk to you about it."

Answer: B

Explanation:

• This is a serious situation. The client should not be offered false hope of

everything being fine.

• If bleeding persists and abortion is imminent or incomplete, the woman may be

hospitalized, Ⅳ therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception.

• The nurse should avoid giving a justification of the miscarriage.
• The nurse should not defer the conversation to someone else (e.g., the

physician).1) The nurse is supervising care in the emergency department. Which situation most requires an intervention?

• Moderate vaginal bleeding at 36 weeks' gestation;

client has an Ⅳ of lactated Ringer's solution running at 125 m L/hour

• Spotting of pinkish-brown discharge at 6 weeks'

gestation and abdominal cramping; ultrasound scheduled in 1 hour

• Bright red bleeding with clots at 32 weeks' gestation;

pulse = 110, blood pressure 90/50, respirations = 20

• Dark red bleeding at 30 weeks' gestation with normal

vital signs; client reports an absence of fetal movement

Answer: C

Explanation:

• Bleeding in the third trimester is usually due to placenta previa or placental

abruption. The primary intervention for placenta previa or placental abruption is intravenous (Ⅳ) therapy, which the patient already has in place.

• Bleeding in the first trimester can be indicative of spontaneous abortion

beginning, or of an ectopic pregnancy. Transvaginal ultrasound is used for diagnosis.

• Bleeding in the third trimester is usually due to placenta previa or placental

abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock.

• Bleeding in the third trimester can indicate placental abruption. Normal vital

signs indicate a normal vascular volume. Decrease in fetal movement or cessation of movement may indicate fetal compromise. The fetus is at greatest risk in this situation; the mother is stable.

1) A client who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain.Laboratory tests reveal a beta-hCG at a lower-than- expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The client is crying and asks what is happening.The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include?

• "You're feeling dizzy because the pregnancy is

compressing your vena cava."

• "The pain is due to the baby putting pressure on

nerves internally."

• "The baby is in the fallopian tube; the tube has

ruptured and is causing bleeding."

• "This is a minor problem. The doctor will be right back

to explain it to you."

Answer: C

Explanation:

• Dizziness from vena cava compression occurs in the third trimester when

women are supine.

• The fetus is too small to be putting pressure on the nerves.
• The woman who experiences one-sided lower abdominal pain or diffused

lower abdominal pain, vasomotor disturbances such as fainting or dizziness, and referred right shoulder pain from blood irritating the subdiaphragmatic phrenic nerve is experiencing an ectopic pregnancy.

• Therapeutic communication requires giving the client an answer rather than

referring the client to someone else.1) A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority?

A) Fluid Volume: Deficient

• Cardiac Output, Decreased
• Injury, Risk for

D) Nutrition, Imbalanced: Less than Body Requirements

Answer: A

Explanation:

• The newly admitted client with hyperemesis gravidarum has been experiencing

excessive vomiting, and is in a fluid volume-deficit state.

• Because no preexisting cardiac condition is present, the body has

compensated for this fluid loss.

• The risk for injury is present due to the symptoms of fluid volume deficit;

however, it is not the priority.

• The nutrition status of the client is compromised until the emesis and the fluid

volume status are corrected. But it is not the first priority.1) The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital

signs are: blood pressure 95/48, pulse 114, respirations 24.

Which order should the nurse implement first?

• Weigh the client.
• Give 1 liter of lactated Ringer's solution Ⅳ.
• Administer 30 m L Maalox (magnesium hydroxide)

orally.

• Encourage clear liquids orally.

Answer: B

Explanation:

• Weighing the client provides information on weight gain or loss, but is not the

top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia.

• The vital signs indicate hypovolemia from dehydration, which leads to

hypotension and increased pulse rate. Giving this client a liter of lactated Ringer's solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

• The vital signs indicate hypovolemia. There is no indication that the client has

dyspepsia.

• Lack of tolerance of oral fluids through excessive vomiting is what has led to

the hypovolemia.

1) A primary herpes simplex infection in the first trimester can increase the risk of which of the following?

• Spontaneous abortion
• Preterm labor
• Intrauterine growth restriction
• Neonatal infection

Answer: A

Explanation:

• A primary herpes simplex infection can increase the risk of spontaneous

abortion when infection occurs in the first trimester.

• Preterm labor (PTL) is a greater risk if the primary infection occurs late in the

second trimester or early in the third trimester.

• Intrauterine growth restriction is a greater risk if the primary infection occurs

late in the second trimester or early in the third trimester.Neonatal infection is a greater risk if the primary infection occurs late in the second trimester or early in the third trimester 1) The nurse is performing a preoperative assessment on a client who is in the second trimester of pregnancy. For which finding(s) should the nurse monitor?

Note: Credit will be given only if all correct choices and

no incorrect choices are selected.Select all that apply.

• Respiratory infection
• Fever
• Urinary tract infection
• Anemia
• ABO incompatibility

Answer: A, B, C, D

Explanation:

• Assessing for respiratory infections is an important part of the preoperative

assessment for the client who is pregnant.

• Assessing for fever is an important part of the preoperative assessment for the

client who is pregnant.

• Assessing for urinary tract infection is an important part of the preoperative

assessment for the client who is pregnant.

• Assessing for anemia is an important part of the preoperative assessment for

the client who is pregnant.

• ABO incompatibility is not routinely assessed as part of the preoperative

assessment for the client who is pregnant, as it rarely has serious life-threatening consequences and is almost exclusively seen after the birth of the newborn.1) The community health nurse is teaching a class about causes of traumatic injury leading to pregnancy complications. What statement should the nurse include in the teaching?

• "Although falls are an uncommon cause of trauma, it is

important to know what to do in the case of these incidents."

• "In early pregnancy, the woman is at a greater risk for

injury due to decreased balance and coordination."

• "The pregnant woman should be given the same care

as any person suffering from trauma."

• "Violence, including domestic violence, is the most

common cause of injury for pregnant women, after motor vehicle accidents."

Answer: D

Explanation:

• Falls are a common cause of trauma in the client who is pregnant.
• Late pregnancy, not early pregnancy, causes a decrease in balance in the client

who is pregnant.

• The physiologic changes that occur with pregnancy have clinical implications

for victims of trauma; the client who is pregnant does not receive the same care.

• Violence, including domestic violence, is the next most common cause of injury

for clients who are pregnant after motor vehicle accidents. This is the statement the nurse should include in the teaching.