Chapter 14 Pregnancy at Risk Gestational Test 1 Flashcards Preview

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Flashcards in Chapter 14 Pregnancy at Risk Gestational Test 1 Deck (46):
1

Women with hyperemesis gravidarum:
a. Are a majority, because 70% of all pregnant women suffer from it at some time.
b. Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance.
c. Need intravenous (IV) fluid and nutrition for most of their pregnancy.
d. Often inspire similar, milder symptoms in their male partners and mothers.

B
Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 70% of pregnant women experience nausea and vomiting, fewer than 1% proceed to this severe level. IV administration may be used at first to restore fluid levels, but they are seldom needed for very long. Women suffering from this condition want sympathy, because some authorities believe that difficult relationships with mothers and/or partners may be the cause.

2

Because pregnant women may need surgery during pregnancy, nurses should be aware that:
a. The diagnosis of appendicitis may be difficult, because the normal signs and symptoms mimic some normal changes in pregnancy.
b. Rupture of the appendix is less likely in pregnant women because of the close monitoring.
c. Surgery for intestinal obstructions should be delayed as long as possible because it usually affects the pregnancy.
d. When pregnancy takes over, a woman is less likely to have ovarian problems that require invasive responses.

A
Both appendicitis and pregnancy are linked with nausea, vomiting, and increased white blood cell count. Rupture of the appendix is two to three times more likely in pregnant women. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a woman to ovarian problems.

3

A client who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, bleeding has been controlled, and the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, discharge teaching should include (choose all that apply):
a. Iron supplementation.
b. Resumption of intercourse at 6 weeks following the procedure.
c. Referral to a support group if necessary.
d. Expectation of heavy bleeding for at least 2 weeks.
e. Emphasizing the need for rest.


A, C, E
The woman should be advised to consume a diet high in iron and protein. For many women iron supplementation also is necessary. Acknowledge that the client has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest. Nothing should be placed in the vagina for 2 weeks after the procedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, she should be instructed to contact her provider.

4

With regard to miscarriage, nurses should be aware that:
a. It is a natural pregnancy loss before labor begins.
b. It occurs in fewer than 5% of all clinically recognized pregnancies.
c. It often can be attributed to careless maternal behavior such as poor nutrition or excessive exercise.
d. If it occurs before the twelfth week of pregnancy, it may present only as moderate discomfort and blood loss.


D
Before the sixth week the only evidence might be a heavy menstrual flow. After the twelfth week more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but by definition it occurs before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 15% of all clinically recognized pregnancies. Miscarriage can be caused by a number of disorders or illnesses outside of the mother’s control or knowledge.

5

Bleeding disorders in late pregnancy include all of these except:
a. Placenta previa. c. Spontaneous abortion.
b. Abruptio placentae. d. Cord insertion.


C
Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy. Placenta previa is a cause of bleeding disorders in later pregnancy. Abruptio placentae is a cause of bleeding disorders in later pregnancy. Cord insertion is a cause of bleeding disorders in later pregnancy.

6

A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure?
a. Amniocentesis for fetal lung maturity
b. Contraction stress test (CST)
c. Ultrasound for placental location
d. Internal fetal monitoring


C
The presence of painless bleeding should always alert the health care team to the possibility of placenta previa. This can be confirmed through ultrasonography. Amniocentesis would not be performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus would be presumed to have immature lungs at this gestational age, and the mother would be given corticosteroids to aid in fetal lung maturity. A CST would not be performed at a preterm gestational age. Furthermore, bleeding would be a contraindication to this test. Internal fetal monitoring would be contraindicated in the presence of bleeding.

7

A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of:
a. Placenta previa.
b. Vasa previa.
c. Severe abruptio placentae.
d. Disseminated intravascular coagulation (DIC).

ANS: B
Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. They are at risk for laceration at anytime, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa. The presence of placenta previa most likely would be ascertained before labor and would be considered a risk factor for this pregnancy. In addition, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a boardlike uterus). DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors.

8

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:
a. Bleeding. c. Uterine activity.
b. Intense abdominal pain. d. Cramping.

B
Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding may be present in varying degrees for both placental conditions. Uterine activity and cramping may be present with both placental conditions.

9

A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the woman’s umbilicus and recognizes this assessment finding as:
a. Normal integumentary changes associated with pregnancy.
b. Turner’s sign associated with appendicitis.
c. Cullen’s sign associated with a ruptured ectopic pregnancy.
d. Chadwick’s sign associated with early pregnancy.

C
Cullen’s sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It presents as a brown, pigmented, vertical line on the lower abdomen. Turner’s sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick’s sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.

10

The antidote administered to reverse magnesium toxicity is _____________________.

Calcium gluconate

11

Methotrexate is recommended as part of the treatment plan for which obstetric complication?
a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae

C
Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for complete hydatidiform mole, missed abortion, and abruptio placentae.

12

The perinatal nurse is giving discharge instructions to a woman, status postsuction curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse would be:
a. “If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available.”
b. “The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.”
c. “If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.”
d. “Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.”

B
This is an accurate statement. -human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a “zero” hCG level. If the woman were to become pregnant, it may obscure the presence of the potentially carcinogenic cells. Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. Any contraceptive method except an intrauterine device is acceptable.

13

_________________________ is responsible for 9% of all maternal mortality and is the leading cause of infertility.

Ectopic pregnancy

14

Preeclampsia is a unique disease process related only to human pregnancy. The exact cause of this condition continues to elude researchers. The American College of Obstetricians and Gynecologists has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors?
a. A 30-year-old obese Caucasian with her third pregnancy
b. A 41-year-old Caucasian primigravida
c. An African-American client who is 19 years old and pregnant with twins
d. A 25-year-old Asian-American, whose pregnancy is the result of donor insemination


C
Three risk factors are present for this woman. She is of African-American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this client the nurse must monitor blood pressure frequently and teach the woman regarding early warning signs. The 30-year-old client only has one known risk factor, obesity. Age distribution appears to be U-shaped, with women less than 20 years and more than 40 years being at greatest risk. Preeclampsia continues to be seen more frequently in primigravidas; this client is a multigravida woman. Two risk factors are present for the 41-year-old client. Her age and status as a primigravida put her at increased risk for preeclampsia. Caucasian women are at a lower risk than African-American women. The Asian-American client exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing preeclampsia.

15

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?
a. Bleeding time of 10 minutes
b. Presence of fibrin split products
c. Thrombocytopenia
d. Hyperfibrinogenemia



B
Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

16

A woman with preeclampsia has a seizure. The nurse’s primary duty during the seizure is to:
a. Insert an oral airway.
b. Suction the mouth to prevent aspiration.
c. Administer oxygen by mask.
d. Stay with the client and call for help.

D
If a client becomes eclamptic, the nurse should stay with him or her and call for help.
Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the client’s head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the client’s mouth. Oxygen would be administered after the convulsion has ended.

17

A woman presents to the emergency department complaining of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?
a. Incomplete c. Threatened
b. Inevitable d. Septic

C
A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would present with heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion presents with the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion presents with malodorous bleeding and typically a dilated cervix.

18

In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder:
a. Disseminated intravascular coagulation (DIC)
b. Amniotic fluid embolism (AFE)
c. Hemorrhage
d. HELLP syndrome


ANS: A
The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman’s arm. Excessive bleeding may occur from the site of a slight trauma such as venipuncture sites. These symptoms are not associated with AFE, nor is AFE a bleeding disorder. Hemorrhage occurs for a variety of reasons in the postpartum client. These symptoms are associated with DIC. Hemorrhage would be a finding associated with DIC and is not a clotting disorder in and of itself. HELLP is not a clotting disorder, but it may contribute to the clotting disorder DIC.

19

Nurses should be aware that chronic hypertension:
a. Is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy.
b. Is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg.
c. Is general hypertension plus proteinuria.
d. Can occur independently of or simultaneously with gestational hypertension.

D
Hypertension is present before pregnancy or diagnosed before 20 weeks of gestation and persists longer than 6 weeks postpartum. The range for hypertension is systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. It becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine. It is a complication of hypertension, not a defining characteristic.

20

The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _________________________.

Placenta previa

21

The nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:
a. Hypertension. c. Hemorrhagic complications.
b. Hyperemesis gravidarum. d. Infections.


A
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women have nausea and vomiting, but a relatively few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common. Hypertension is the most common medical complication of pregnancy.

22

Magnesium sulfate is given to women with preeclampsia and eclampsia to:
a. Improve patellar reflexes and increase respiratory efficiency.
b. Shorten the duration of labor.
c. Prevent and treat convulsions.
d. Prevent a boggy uterus and lessen lochial flow.

C
Magnesium sulfate is the drug of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

23

Your client has been on magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings would you expect to observe/assess in this client?
a. Absence of uterine bleeding in the postpartum period
b. A fundus firm below the level of the umbilicus
c. Scant lochia flow
d. A boggy uterus with heavy lochia flow

D
Because of the tocolytic effects of magnesium sulfate, this client most likely would have a boggy uterus with increased amounts of bleeding and a heavy lochia flow in the postpartum period.

24

Your client is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, “Why is it taking so long?” The most appropriate response by the nurse would be:
a. “The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.”
b. “I don’t know why it is taking so long.”
c. “The length of labor varies for different women.”
d. “Your baby is just being stubborn.”

A
Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. “I don’t know why it is taking so long.” is not an appropriate statement for the nurse to make. Although the length of labor does vary for difference women, the most likely reason this woman’s labor is protracted is the tocolytic effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.

25

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?
a. Administration of blood
b. Preparation of the client for invasive hemodynamic monitoring
c. Restriction of intravascular fluids
d. Administration of steroids


A
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 client with DIC because this can contribute to more areas of bleeding. Management of DIC would include volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.

26

In planning care for women with preeclampsia, nurses should be aware that:
a. Induction of labor is likely, as near term as possible.
b. If at home, the woman should be confined to her bed, even with mild preeclampsia.
c. A special diet low in protein and salt should be initiated.
d. Vaginal birth is still an option, even in severe cases.


A
Induction of labor is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate delivery may not be in the best interest of the fetus. Strict bed rest is becoming controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are much the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe preeclampsia should expect a cesarean delivery.

27

Nurses should be aware that HELLP syndrome:
a. Is a mild form of preeclampsia.
b. Can be diagnosed by a nurse alert to its symptoms.
c. Is characterized by hemolysis, elevated liver enzymes, and low platelets.
d. Is associated with preterm labor but not perinatal mortality.


C
The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. HELLP syndrome is difficult to identify because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased and so is perinatal mortality.

28

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. A dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day


C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made. Generally hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or 15 mm Hg diastolic pressure. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies and in women with preeclampsia. Therefore the presence of edema is no longer considered diagnostic of preeclampsia.

29

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman’s latest laboratory test findings, which reveal a platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the laboratory results are indicative of:
a. Eclampsia.
b. Disseminated intravascular coagulation (DIC).
c. HELLP syndrome.
d. Idiopathic thrombocytopenia.

C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.

30

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment the nurse finds the following vital signs: temperature of 37.3° C, pulse rate of 88 beats/min, respiratory rate of 10 breaths/min, blood pressure (BP) of 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, “I’m so thirsty and warm.” The nurse:
a. Calls for a stat magnesium sulfate level.
b. Administers oxygen.
c. Discontinues the magnesium sulfate infusion.
d. Prepares to administer hydralazine.

ANS: C
The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over 110 mm Hg.

31

A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:
a. Hydralazine. c. Diazepam.
b. Magnesium sulfate bolus. d. Calcium gluconate.

A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over 110 mm Hg. 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.

32

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:
a. Eclamptic seizure. c. Placenta previa.
b. Rupture of the uterus. d. Placental abruption.


D
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. 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.

33

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:
a. A sleepy, sedated affect.
b. A respiratory rate of 10 breaths/min.
c. Deep tendon reflexes of 2
d. Absent ankle clonus.

B
A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a central nervous system depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2 and absent ankle clonus are normal findings.

34

What nursing diagnosis would be the most appropriate for a woman experiencing severe preeclampsia?
a. Risk for injury to the fetus related to uteroplacental insufficiency
b. Risk for eclampsia
c. Risk for deficient fluid volume related to increased sodium retention secondary to administration of MgSO4
d. Risk for increased cardiac output related to use of antihypertensive drugs

A
Risk for injury to the fetus related to uteroplacental insufficiency is the most appropriate nursing diagnosis for this client scenario. Other diagnoses include risk to fetus related to preterm birth and abruptio placentae. Eclampsia is a medical, not a nursing, diagnosis. There would be a risk for excess, not deficient, fluid volume related to increased sodium retention. There would be a risk for decreased, not increased, cardiac output related to the use of antihypertensive drugs.

35

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?

A. “I will not experience mood swings since I was only at 10 weeks of gestation.”
B. “I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months.”
C. “I should eat foods that are high in iron and protein to help my body heal.”
D. “I should expect the bleeding to be heavy and bright red for at least 1 week."

C.
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.

36

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits:

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

B.
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.

37

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.)

A. Eat three larger meals a day.
B. Eat a high-protein snack at bedtime.
C. Ice cream may stay down better than other foods.
D. Avoid ginger tea or sweet drinks.
E. Eat what sounds good to you even if your meals are not well-balanced.

B. C. E.

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.

38


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.)

A. Place the patient in a supine position.
B. Assess for point of maximal impulse at fourth intercostal space.
C. Collect urine for urinalysis and culture.
D. Frequent vital sign monitoring.
E. Assist with ambulation to decrease risk of thrombosis.

B. C. D.

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.

39

A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for:

A. hemorrhage.
B. infection.
C. urinary retention.
D. thrombophlebitis.

A.
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.

40

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.)

A. Decreased urinary output and irritability
B. Transient headache and +1 proteinuria
C. Ankle clonus and epigastric pain
D. Platelet count of less than 100,000/mm3 and visual problems
E. Seizure activity and hypotension

A. C. D.
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.

41

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?

A. Prepare the woman for a dilation and curettage (D&C).
B. Place the woman on bed rest for at least 1 week and reevaluate.
C. Prepare the woman for an ultrasound and blood work.
D. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.


C.
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.

42

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

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

B.
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.

43

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate?

A. Administration of blood
B. Preparation of the woman for invasive hemodynamic monitoring
C. Restriction of intravascular fluids
D. Administration of steroids


A.
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.

44

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:

A. hydralazine.
B. magnesium sulfate bolus .
C. diazepam.
D. calcium gluconate.

A. Hydralazine

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.

45

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:

A. bleeding.
B. intense abdominal pain.
C. uterine activity.
D. cramping.

B. intense abdominal pain

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.

46

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:

A. eclamptic seizure.
B. rupture of the uterus.
C. placenta previa.
D. placental abruption.


D. placental abruption

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.