Flashcards in Chapter 28 Deck (37):
1. A pregnant woman is being discharged from the hospital after the placement of a cervical cerclage because of a history of recurrent pregnancy loss, secondary to an incompetent cervix. Which information regarding postprocedural care should the nurse emphasize in the discharge teaching?
a. Any vaginal discharge should be immediately reported to her health care provider.
b. The presence of any contractions, rupture of membranes (ROM), or severe perineal pressure should be reported.
c. The client will need to make arrangements for care at home, because her activity level will be restricted.
d. The client will be scheduled for a cesarean birth.
Nursing care should stress the importance of monitoring for the signs and symptoms of preterm labor. Vaginal bleeding needs to be reported to her primary health care provider. Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the woman’s need for visits and to monitor her status safely at home. The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned.
2. A perinatal nurse is giving discharge instructions to a woman, status postsuction, and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. What is the best response by the nurse?
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, then 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, not getting pregnant at this time is best.”
d. “Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.”
Beta–human chorionic gonadotropin (beta-hCG) hormone levels are drawn for 1 year to ensure that the mole is completely gone. The chance of developing choriocarcinoma after the development of a hydatidiform mole is increased. Therefore, the goal is to achieve a zero human chorionic gonadotropin (hCG) level. If the woman were to become pregnant, then 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 (IUD) is acceptable.
3. The nurse is preparing to administer methotrexate to the client. This hazardous drug is most often used for which obstetric complication?
a. Complete hydatidiform mole
b. Missed abortion
c. Unruptured ectopic pregnancy
d. Abruptio placentae
Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and measures less than 4 cm in diameter. Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole, for a missed abortion, or for abruptio placentae.
4. 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, which diagnostic procedure will the client most likely have performed?
a. Amniocentesis for fetal lung maturity
b. Transvaginal ultrasound for placental location
c. Contraction stress test (CST)
d. Internal fetal monitoring
The presence of painless bleeding should always alert the health care team to the possibility of placenta previa, which can be confirmed through ultrasonography. Amniocentesis is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother is given corticosteroids to aid in fetal lung maturity. A CST is not performed at a preterm gestational age. Furthermore, bleeding is a contraindication to a CST. Internal fetal monitoring is also contraindicated in the presence of bleeding.
5. A laboring woman with no known risk factors suddenly experiences spontaneous ROM. The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. No change in uterine resting tone has occurred. The fetal heart rate (FHR) begins to decline rapidly after the ROM. The nurse should suspect the possibility of what condition?
a. Placenta previa
b. Vasa previa
c. Severe abruptio placentae
d. Disseminated intravascular coagulation (DIC)
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. The umbilical blood vessels thus are at risk for laceration at any time, 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 FHR 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 is 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 typically is 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 the hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome. This woman did not have any prior risk factors.
6. A woman arrives for evaluation of signs and symptoms that 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. What does this finding indicate?
a. Normal integumentary changes associated with pregnancy
b. Turner sign associated with appendicitis
c. Cullen sign associated with a ruptured ectopic pregnancy
d. Chadwick sign associated with early pregnancy
Cullen sign, the blue ecchymosis observed 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 and exhibits a brown pigmented, vertical line on the lower abdomen. Turner sign is ecchymosis in the flank area, often associated with pancreatitis. A Chadwick sign is a blue-purple cervix that may be seen during or around the eighth week of pregnancy.
7. The nurse who elects to practice in the area of women’s health must have a thorough understanding of miscarriage. Which statement regarding this condition is most accurate?
a. A miscarriage is a natural pregnancy loss before labor begins.
b. It occurs in fewer than 5% of all clinically recognized pregnancies.
c. Careless maternal behavior, such as poor nutrition or excessive exercise, can be a factor in causing a miscarriage.
d. If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as moderate discomfort and blood loss.
Before the sixth week, the only evidence might be a heavy menstrual flow. After the 12th week, more severe pain, similar to that of labor, is likely. Miscarriage is a natural pregnancy loss, but it occurs, by definition, before 20 weeks of gestation, before the fetus is viable. Miscarriages occur in approximately 10% to 15% of all clinically recognized pregnancies. Miscarriages can be caused by a number of disorders or illnesses outside the mother’s control or knowledge.
8. A woman who is 30 weeks of gestation arrives at the hospital with bleeding. Which differential diagnosis would not be applicable for this client?
a. Placenta previa
b. Abruptio placentae
c. Spontaneous abortion
d. Cord insertion
Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in pregnancy. Placenta previa is a well-known reason for bleeding late in pregnancy. The premature separation of the placenta (abruptio placentae) is a bleeding disorder that can occur late in pregnancy. Cord insertion may cause a bleeding disorder that can also occur late in pregnancy.
9. With regard to hemorrhagic complications that may occur during pregnancy, what information is most accurate?
a. An incompetent cervix is usually not diagnosed until the woman has lost one or two pregnancies.
b. Incidences of ectopic pregnancy are declining as a result of improved diagnostic techniques.
c. One ectopic pregnancy does not affect a woman’s fertility or her likelihood of having a normal pregnancy the next time.
d. Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic malignancies.
Short labors and recurring losses of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence. Because diagnostic technology is improving, more ectopic pregnancies are being diagnosed. One ectopic pregnancy places the woman at increased risk for another one. Ectopic pregnancy is a leading cause of infertility. Once invariably fatal, GTN now is the most curable gynecologic malignancy.
10. The management of the pregnant client who has experienced a pregnancy loss depends on the type of miscarriage and the signs and symptoms. While planning care for a client who desires outpatient management after a first-trimester loss, what would the nurse expect the plan to include?
a. Dilation and curettage (D&C)
b. Dilation and evacuation (D&E)
d. Ergot products
Outpatient management of a first-trimester loss is safely accomplished by the intravaginal use of misoprostol for up to 2 days. If the bleeding is uncontrollable, vital signs are unstable, or signs of infection are present, then a surgical evacuation should be performed. D&C is a surgical procedure that requires dilation of the cervix and scraping of the uterine walls to remove the contents of pregnancy. This procedure is commonly performed to treat inevitable or incomplete abortion and should be performed in a hospital. D&E is usually performed after 16 weeks of pregnancy. The cervix is widely dilated, followed by removal of the contents of the uterus. Ergot products such as Methergine or Hemabate may be administered for excessive bleeding after miscarriage.
11. Which laboratory marker is indicative of DIC?
a. Bleeding time of 10 minutes
b. Presence of fibrin split products
Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the body’s vasculature. Bleeding time in DIC is normal. Low platelets may occur but are not indicative of DIC because they may be the result from other coagulopathies. Hypofibrinogenemia occurs with DIC.
12. When is a prophylactic cerclage for an incompetent cervix usually placed (in weeks of gestation)?
a. 12 to 14
b. 6 to 8
c. 23 to 24
d. After 24
A prophylactic cerclage is usually placed at 12 to 14 weeks of gestation. The cerclage is electively removed when the woman reaches 37 weeks of gestation or when her labor begins. Six to 8 weeks of gestation is too early to place the cerclage. Cerclage placement is offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks. Although no consensus has been reached, 24 weeks is used as the upper gestational age limit for cerclage placement.
13. In caring for an immediate postpartum client, the nurse notes petechiae and oozing from her intravenous (IV) site. The client would be closely monitored for which clotting disorder?
b. Amniotic fluid embolism (AFE)
d. HELLP syndrome
The diagnosis of DIC is made according to clinical findings and laboratory markers. A 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 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 syndrome is not a clotting disorder, but it may contribute to the clotting disorder DIC.
14. In caring for the woman with DIC, which 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
Primary medical management in all cases of DIC involves a 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 initially ordered in a client with DIC because it could 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.
15. A woman arrives at the emergency department with complaints 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 woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion demonstrates the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion has malodorous bleeding and typically a dilated cervix.
16. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae?
b. Intense abdominal pain
c. Uterine activity
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.
17. Which maternal condition always necessitates delivery by cesarean birth?
a. Marginal placenta previa
b. Complete placenta previa
c. Ectopic pregnancy
In complete placenta previa, the placenta completely covers the cervical os. A cesarean birth is the acceptable method of delivery. The risk of fetal death occurring is due to preterm birth. If the previa is marginal (i.e., 2 cm or greater away from the cervical os), then labor can be attempted. A cesarean birth is not indicated for an ectopic pregnancy. Labor can be safely induced if the eclampsia is under control.
18. What is the correct definition of a spontaneous termination of a pregnancy (abortion)?
a. Pregnancy is less than 20 weeks.
b. Fetus weighs less than 1000 g.
c. Products of conception are passed intact.
d. No evidence exists of intrauterine infection.
An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some older fetuses may have a low birth weight. A spontaneous abortion may be complete or incomplete and may be caused by many problems, one being intrauterine infection.
19. What is the correct terminology for an abortion in which the fetus dies but is retained within the uterus?
a. Inevitable abortion
b. Missed abortion
c. Incomplete abortion
d. Threatened abortion
Missed abortion refers to the retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion, the woman has cramping and bleeding but no cervical dilation.
20. What condition indicates concealed hemorrhage when the client experiences abruptio placentae?
a. Decrease in abdominal pain
c. Hard, boardlike abdomen
d. Decrease in fundal height
Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. Abdominal pain may increase. The client will have shock symptoms that include tachycardia. As bleeding occurs, the fundal height increases.
21. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
a. Assessing FHR and maternal vital signs
b. Performing a venipuncture for hemoglobin and hematocrit levels
c. Placing clean disposable pads to collect any drainage
d. Monitoring uterine contractions
Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. The most important assessment is to check the well-being of both the mother and the fetus. The blood levels can be obtained later. Assessing future bleeding is important; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not a top priority.
22. Which order should the nurse expect for a client admitted with a threatened abortion?
a. Bed rest
b. Administration of ritodrine IV
c. Nothing by mouth (nil per os [NPO])
d. Narcotic analgesia every 3 hours, as needed
Decreasing the woman’s activity level may alleviate the bleeding and allow the pregnancy to continue. Ritodrine is not the first drug of choice for tocolytic medications. Having the woman placed on NPO is unnecessary. At times, dehydration may produce contractions; therefore, hydration is important. Narcotic analgesia will not decrease the contractions and may mask the severity of the contractions.
23. Which finding on a prenatal visit at 10 weeks of gestation might suggest a hydatidiform mole?
a. Complaint of frequent mild nausea
b. Blood pressure of 120/80 mm Hg
c. Fundal height measurement of 18 cm
d. History of bright red spotting for 1 day, weeks ago
The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the client’s history, bleeding is normally described as brownish.
24. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Which information assists the nurse in developing the plan of care?
a. Bed rest and analgesics are the recommended treatment.
b. She will be unable to conceive in the future.
c. A D&C will be performed to remove the products of conception.
d. Hemorrhage is the primary concern.
Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture to prevent hemorrhaging. If the tube must be removed, then the woman’s fertility will decrease; however, she will not be infertile. A D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.
1. A client who has undergone a D&C for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that her vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. To promote an optimal recovery, what information should discharge teaching include? (Select all that apply.)
a. Iron supplementation
b. Resumption of intercourse at 6 weeks postprocedure
c. Referral to a support group, if necessary
d. Expectation of heavy bleeding for at least 2 weeks
e. Emphasizing the need for rest
ANS: 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. The nurse should acknowledge that the client has experienced a loss, however 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, including 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 health care provider.
2. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.)
a. Chromosomal abnormalities
c. Endocrine imbalance
d. Systemic disorders
ANS: A, C, D, E
Infections are not a common cause of early miscarriage. At least 50% of pregnancy losses result from chromosomal abnormalities. Endocrine imbalances such as hypothyroidism or diabetes are also possible causes for early pregnancy loss. Other systemic disorders that may contribute to pregnancy loss include lupus and genetic conditions. Although infections are not a common cause of early miscarriage, varicella infection in the first trimester has been associated with pregnancy loss.
3. The reported incidence of ectopic pregnancy has steadily risen over the past 2 decades. Causes include the increase in sexually transmitted infections (STIs) accompanied by tubal infection and damage. The popularity of contraceptive devices such as the IUD has also increased the risk for ectopic pregnancy. The nurse suspects that a client has early signs of ectopic pregnancy. The nurse should be observing the client for which signs or symptoms? (Select all that apply.)
a. Pelvic pain
b. Abdominal pain
c. Unanticipated heavy bleeding
d. Vaginal spotting or light bleeding
e. Missed period
ANS: A, B, D, E
A missed period or spotting can be easily mistaken by the client as an early sign of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage, which may progress to hypovolemic shock with minimal or even no external bleeding. In approximately one half of women, shoulder and neck pain results from irritation of the diaphragm from the hemorrhage.
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 health care provider finds that the cervix is closed. The anticipated plan of care for this woman is based on a probable diagnosis of which type of spontaneous abortion?
A woman with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. Heavy bleeding, mild to severe cramping, and cervical dilation are the presentation for both incomplete abortion and inevitable abortion. A woman with a septic abortion presents with malodorous bleeding and, typically, a dilated cervix.
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is:
b. Intense abdominal pain.
c. Uterine activity.
Pain is absent with placenta previa and may be agonizing with abruptio placentae. Bleeding, uterine activity, and cramping may be present in varying degrees for 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 to 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.
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 manifests with hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain, and placenta previa with bright red, painless vaginal bleeding.
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
Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement (not volume restriction), 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 it could contribute to more areas of bleeding. 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?
a. Prepare the woman for a dilation and curettage (D&C).
b. Put 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.
Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine whether the fetus is alive and within the uterus. Bed rest is recommended for 48 hours initially. D&C is not considered until signs of the progress to inevitable abortion are noted or the contents are expelled and incomplete. 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 present she is at the greatest risk for:
c. Urinary retention.
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 or thrombophlebitis than does a normally implanted placenta.
A nurse is evaluating several obstetric patients for their risk for cervical insufficiency. Which patient would be considered to be most at risk?
b. Grandmultip who has previously had all vaginal deliveries without a problem
c. Primip who undergoes a cervical cone biopsy for cervical dysplasia prior to the pregnancy
d. Multip who had her previous delivery via C section due to cephalopelvic disproportion (CPD)
Any patient who has had previous surgical interventions (cone biopsy) is at greater risk for cervical insufficiency. There is no indication that a primip is at risk for cervical insufficiency. A grandmultip who has previously had vaginal deliveries without incidence is not necessarily at an increased risk for cervical insufficiency. A multip who has delivered via C section as a result of CPD would not necessarily be at an increased risk as the issue involves pelvic adequacy as determined by pelvic measurements in relationship to the fetus.
The majority of ectopic pregnancies are located in the:
a. Uterine fundus.
b. Cervical os.
A pregnancy within the uterus would be considered a normal pregnancy. Implantation of the pregnancy at the cervical os would be a significant abnormality. The majority of ectopic pregnancies, approximately 80%, are located in the ampulla or largest portion of the tube.
A nurse is examining a patient who has been admitted for possible ectopic pregnancy who is approximately 8 weeks pregnant. Which finding would be a priority concern?
a. No FHT heard via Doppler
b. Scant vaginal bleeding noted on peri pad
c. Ecchymosis noted around umbilicus
d. Blood pressure 100/80
Because this patient is most likely in the early stages of pregnancy, FHT would not be able to be auscultated at this time. Scant vaginal bleeding would not be a priority concern but should still be monitored by the nurse. Ecchymosis around the umbilicus indicates Cullen sign, which indicates hematoperitoneum, and may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.