Perry - Chapter 12 Flashcards
(45 cards)
Women with hyperemesis gravidarum:
a. Are a majority, because 80% 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.
ANS: B
Women with hyperemesis gravidarum have severe vomiting; however, treatment for several days sets things right in most cases. Although 80% of pregnant women experience nausea and vomiting, fewer than 1% (0.5%) proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is 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.
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.
ANS: 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.
What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?
a. Bleeding time of 10 minutes c. Thrombocytopenia
b. Presence of fibrin split products d. Hyperfibrinogenemia
ANS: 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.
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 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.
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
ANS: 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.
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
ANS: 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 in diastolic pressure of 15 mm Hg. 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.
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.
ANS: 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.
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.
ANS: D
If a client becomes eclamptic, the nurse should stay 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.
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 greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg.
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.
ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 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.
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.
ANS: 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 manifests as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa manifests with bright red, painless vaginal bleeding.
The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:
a. A sleepy, sedated affect. c. Deep tendon reflexes of 2.
b. A respiratory rate of 10 breaths/min. d. Absent ankle clonus.
ANS: 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.
Your patient has been receiving 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
ANS: D
Because of the tocolytic effects of magnesium sulfate, this patient most likely would have a boggy uterus with increased amounts of bleeding and a heavy lochia flow in the postpartum period.
Your patient 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.”
ANS: 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 in different women, the most likely reason this woman’s labor is protracted is the tocolytic effect of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.
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
ANS: 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.
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.
ANS: A
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will 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.
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.
ANS: 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.
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.
ANS: 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.
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.
ANS: 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.
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.
ANS: 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.
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
ANS: 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.
A woman presents to 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. Incomplete c. Threatened
b. Inevitable d. Septic
ANS: 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 manifests 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.
The perinatal nurse is giving discharge instructions to a woman after suction 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.”
ANS: 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 could 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.
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.
ANS: 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.
