Chapter 14: Pregnancy at Risk: Gestational Conditions

Question 1

1. What is a nurse aware of related to patients who experience hyperemesis gravidarum?
   a. Seventy percent of all pregnant patients suffer from it at some point in pregnancy.
   b. Such patients have vomiting severe and persistent enough to cause weight loss,
   dehydration, and electrolyte imbalance.
   c. Patients need intravenous (IV) fluid and nutrition for most of their pregnancy.
   d. Pregnant patients often inspire similar, milder symptoms in their partners and
   mothers.

Answer 1

ANS: B
Patients 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, about 0.5% to 2% proceed to this severe level. IV administration may be used at first to restore fluid levels, but it is seldom needed for very long. Patients who have this condition want sympathy, because some authorities believe that difficult relationships with mothers or partners may be the cause.

Question 2

2. What should a nurse be aware of in relation to patients who may need surgery during pregnancy?
   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 patients 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 patient is less likely to have ovarian problems that
   require invasive responses.

Answer 2

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 patients. Surgery to remove obstructions should be done right away. It usually does not affect the pregnancy. Pregnancy predisposes a patient to ovarian problems.

Question 3

3. Which laboratory result is indicative of disseminated intravascular coagulation (DIC)?
   a. Increased platelets
   b. Decreased fibrinogen
   c. Increased factor V
   d. Decreased fibrin degradation fragment

Answer 3

ANS: B
Decreased fibrinogen is seen with DIC. With DIC, platelets are decreased, factor V is decreased, and fibrin degradation fragment is increased.

Question 4

4. In caring for an immediate postpartum patient, a nurse notes petechiae and oozing from an IV site. Based on this assessment, what clotting disorder would the nurse monitor this patient closely for?
   a. Disseminated intravascular coagulation (DIC)
   b. Amniotic fluid embolism (AFE)
   c. Hemorrhage
   d. HELLP syndrome

Answer 4

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 patient’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 patient. 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.

Question 5

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

Answer 5

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 patient 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.

Question 6

6. A nurse is concerned about which finding in a primigravida that is being monitored in the prenatal clinic for pre-eclampsia?
   a. Blood pressure (BP) increase to 138/86 mm Hg
   b. Weight gain of 0.5 kg during the past 2 weeks
   c. Urine protein reading of 0.05 g/L on two occasions
   d. Pitting pedal edema at the end of the day

Answer 6

Proteinuria is defined as a concentration of 0.03 g/L in at least two random urine specimens collected at least 6 hours apart and should alert the nurse that additional testing or assessment should be made. Generally, hypertension is defined as a BP of 140/90. Pre-eclampsia is not related to weight gain. Edema occurs in many normal pregnancies and in women with pre-eclampsia. Therefore, the presence of edema is no longer considered diagnostic of pre-eclampsia.

Question 7

reviews the patient’s latest laboratory test findings, which reveal a platelet count of 96  10 /L, an elevated aspartate transaminase(AST) level, and a falling hematocrit. What are these findings indicative of?
a. Eclampsia
b. Disseminated intravascular coagulation (DIC)
c. HELLP syndrome
d. Idiopathic thrombocytopenia

Answer 7

ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe pre-eclampsia 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 pre-eclampsia.

Question 8

8. A pregnant patient with pre-eclampsia has a seizure. What is a nurse’s priority intervention?
   a. Ensure a patent airway.
   b. Suction the mouth to prevent aspiration.
   c. Administer oxygen by mask.
   d. Turn the patient on their side.

Answer 8

ANS: A
If a patient becomes eclamptic, the priority intervention is to ensure a patent airway. The nurse should attempt to keep the airway patent by turning the patient’s head to the side to prevent aspiration. The nurse should not try to turn a patient who has a seizure until after the seizure has ended. Once the seizure has ended, it may be necessary to suction the patient’s mouth. Oxygen would be administered after the convulsion has ended.

Question 9

9. A pregnant patient has been receiving a magnesium sulphate infusion for treatment of severe pre-eclampsia for 24 hours. On assessment a 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 patient states, “I’m so thirsty and warm.” What is the nurse’s initial intervention?
   a. Call for a stat magnesium sulphate level.
   b. Administer oxygen.
   c. Discontinue the magnesium sulphate infusion.
   d. Prepare to administer hydralazine.

Answer 9

ANS: C
The patient is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. Waiting for the results of a laboratory test may make matters worse. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive commonly used to treat hypertension in severe pre-eclampsia. Typically it is administered for a systolic BP over 160 mm Hg or a diastolic BP over 110 mm Hg.

Question 10

the patient 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. Which medication should the nurse anticipate will be ordered for this patient?
a. Hydralazine
b. Magnesium sulphate bolus
c. Diazepam
d. Calcium gluconate

Answer 10

ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe pre-eclampsia. 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 sulphate may be ordered for increasing signs of central nervous system irritability related to severe pre-eclampsia (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 sulphate toxicity. The patient is not currently displaying any signs or symptoms of magnesium toxicity.

Question 11

11. A patient at 39 weeks of gestation with a history of pre-eclampsia is admitted to the labour and birth unit. The patient 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 which condition?
    a. Eclamptic seizure
    b. Rupture of the uterus
    c. Placenta previa
    d. Placental abruption

Answer 11

ANS: D
Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (placental abruption). Patients 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.

Question 12

12. Which should a nurse be concerned about when caring for a pregnant patient with severe pre-eclampsia who is receiving a magnesium sulphate infusion?
    a. A sleepy, sedated affect
    b. A respiratory rate of 10 breaths/min
    c. Deep tendon reflexes of 2
    d. Absent ankle clonus

Answer 12

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

Question 13

13. A patient has been on magnesium sulphate for 20 hours for treatment of pre-eclampsia. They have just given birth to a newborn infant 30 minutes ago. What uterine findings would a nurse expect to assess in this patient?
    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

Answer 13

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

Question 14

14. What would a nurse teach a patient who had a hydatidiform mole regarding follow-up care?
    a. The follow-up assessment period is generally 2 years
    b. Weekly hCG levels until normal for 3 consecutive weeks
    c. Pregnancy is to be avoided for at least 3 months
    d. Monthly serum -hCG for 6 months

Answer 14

D
Follow-up management includes frequent physical and pelvic examinations along with measurement of serum -hCG until the level drops to normal and remains normal for 3 weeks. Monthly measurements are taken for 6 months. Follow-up assessment period usually continues for 1 year, not 2 years.

Question 15

15. What is the classification of placenta previa when the placental edge is 2.0 cm from the internal cervical os?
    a. Complete
    b. Marginal
    c. Class 2
    d. Class 3

Answer 15

ANS: B
In a marginal placenta previa, the edge of the placenta is seen on transvaginal ultrasound as 2.5 cm or closer to the internal cervical os, whereas with a complete placenta previa, the placenta covers the internal cervical os totally. Class is not a classi fication of placenta previa but is used to classify placental abruption.

Question 16

16. A nurse is aware that what is the most common medical complication of pregnancy?
    a. Hypertension
    b. Hyperemesis gravidarum
    c. Hemorrhagic complications
    d. Infections

Answer 16

ANS: A
A large percentage of pregnant women have nausea and vomiting, but 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.

Question 17

17. A nurse is aware that which is true in relation to HELLP syndrome?
    a. It is a mild form of pre-eclampsia.
    b. It can be diagnosed by a nurse alert to its symptoms.
    c. It is characterized by hemolysis, elevated liver enzymes, and low platelets.
    d. It is associated with preterm labour but not perinatal mortality.

Answer 17

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

Question 18

18. A nurse is aware that which statement is true of chronic hypertension?
    a. It is defined as hypertension that begins during pregnancy and lasts for the
    duration of pregnancy.
    b. It 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. It is general hypertension plus proteinuria.
    d. It can be accompanied by pre-eclampsia during pregnancy.

Answer 18

ANS: D
Chronic hypertension is present before pregnancy or diagnosed before 20 weeks of gestation. It can occur with pre-eclampsia as well as other comorbid conditions. 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.

Question 19

19. What should a nurse be aware of when planning care for patients with pre-eclampsia?
    a. Induction of labour is likely, as near term as possible.
    b. If at home, the patient should be confined to their bed, even with mild
    pre-eclampsia.
    c. A special diet low in protein and salt should be initiated.
    d. Caesarean birth is the best option.

Answer 19

ANS: A
Induction of labour is likely, as near term as possible; however, at less than 37 weeks of gestation, immediate birth may not be in the best interest of the fetus. Patients with pre-eclampsia should be hospitalized and strict bedrest is not recommended. Diet and fluid recommendations are much the same as those for healthy pregnant patients, although some authorities have suggested a diet high in protein. Vaginal birth is the preferred type of birth, and Caesarean birth should only be performed for obstetrical indications.

Question 20

20. Why would a nurse administer magnesium sulphate that is prescribed to patients with pre-eclampsia and eclampsia?
    a. It improves patellar reflexes and increases respiratory efficiency.
    b. It shortens the duration of labour.
    c. It prevents or controls convulsions.
    d. It prevents a boggy uterus and lessens lochial flow.

Answer 20

ANS: C
Magnesium sulphate is the medication of choice to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulphate can increase the duration of labour. Postpartum patients are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulphate therapy.

Question 21

21. A nurse would be most concerned about which patient regarding risk factors associated with pre-eclampsia?
    a. A 30-year-old obese White woman with her third pregnancy
    b. A 41-year-old White primigravida
    c. An Inuit patient who is 42 years old, weighs 92 kg, and is pregnant with twins
    d. A 25-year-old Métis woman whose pregnancy is the result of donor insemination

Answer 21

ANS: C
Three risk factors are present for this woman. She is obese, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this patient, the nurse must monitor blood pressure frequently and teach the woman about early warning signs. The 30-year-old patient only has one known risk factor: obesity. Women more than 40 years of age are at greatest risk. Pre-eclampsia continues to be seen more frequently in primigravidas; this patient is a multigravida woman. Two risk factors are present for the 41-year-old patient. Their age and status as a primigravida put them at increased risk for pre-eclampsia. The Métis patient exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing pre-eclampsia.

Question 22

22. A patient presents to the emergency department with symptoms 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 patient would be based on a probable diagnosis of which type of spontaneous abortion?
    a. Incomplete
    b. Inevitable c. Threatened d. Septic

Answer 22

ANS: C
A patient with a threatened abortion presents with spotting, mild cramps, and no cervical dilation. A patient 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 patient with a septic abortion presents with malodorous bleeding and typically a dilated cervix.

Question 23

23. A nurse is giving discharge instructions to a woman who had a suction curettage secondary to a hydatidiform mole. The patient asks why they must take oral contraceptives for the next 12 months. What is the basis for the nurse’s response?
    a. The chance of a successful pregnancy within 1 year of this condition is very
    small.
    b. A major risk after a molar pregnancy is a type of cancer that can be diagnosed
    only by measuring the same hormone that the body produces during pregnancy;
    therefore, pregnancy would make the diagnosis of this cancer more difficult.
    c. The chance of developing a second molar pregnancy after 1 year is rare.
    d. Oral contraceptives are the only form of birth control that will prevent a
    recurrence of a molar pregnancy.

Answer 23

ANS: B
This is an accurate statement. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. Beta-human chorionic gonadotropin (hCG) levels will be drawn for 1 year to ensure that the mole is completely gone; the goal is to achieve a “zero” hCG level. If the woman were to become pregnant, the pregnancy might 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 detection of potential carcinogenic cells is possible. Any contraceptive method except an intrauterine device is acceptable.

Question 24

24. A nurse suspects a patient has a placental abruption, as opposed to placenta previa based on which clinical manifestation?
    a. Bleeding
    b. Intense abdominal pain
    c. Uterine activity
    d. Cramping

Answer 24

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

Question 25

25. A nurse would administer methotrexate as part of the treatment plan for which obstetrical complication?
    a. Complete hydatidiform mole
    b. Missed abortion
    c. Unruptured ectopic pregnancy
    d. Abruptio placentae

Answer 25

ANS: C
Methotrexate is an effective, nonsurgical treatment option for a hemodynamically stable patient whose ectopic pregnancy is unruptured. Methotrexate is not indicated or recommended as a treatment option for complete hydatidiform mole, missed abortion, or abruptio placentae.

Question 26

26. A 26-year-old pregnant patient, 2-1-0-0-1, is 28 weeks pregnant when they experience bright red, painless vaginal bleeding. On their arrival at the hospital, what diagnostic procedure would a prepare the patient for?
    a. Amniocentesis for fetal lung maturity
    b. Ultrasound for placental location
    c. Contraction stress test (CST)
    d. Internal fetal monitoring

Answer 26

ANS: B
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 patient who is experiencing bleeding. In the event of an imminent birth, 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.

Question 27

27. A nurse is aware that what condition occurs when some of the umbilical vessels cross the cervical os below the presenting part?
    a. Placenta previa
    b. Vasa previa
    c. Severe abruptio placentae
    d. Disseminated intravascular coagulation (DIC)

Answer 27

ANS: B
Vasa previa is occurring when some of the umbilical vessels cross the cervical os below the presenting part. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The presence of placenta previa most likely would be ascertained before labour and would be considered a risk factor for this pregnancy. With the presence of severe abruptio placentae, the uterine tonicity would typically be tetanus (i.e., a boardlike uterus). DIC is a pathological form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both.

Question 28

28. A patient arrives for evaluation of their symptoms, which include a missed period, adnexal fullness, tenderness, and dark red
    vaginal bleeding. On examination a nurse notices an ecchymotic blueness around the woman’s umbilicus. How should the nurse
    interpret this assessment finding?
    a. This is a normal integumentary change associated with pregnancy.
    b. This is Turner sign, associated with appendicitis.
    c. This is Cullen sign, associated with a ruptured ectopic pregnancy.
    d. This is Chadwick sign, associated with early pregnancy.

Answer 28

ANS: C
Cullen sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intra-abdominal 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 sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwick sign is the blue–purple colour of the cervix that may be seen during or around the eighth week of pregnancy.

Question 29

29. What should nurses be aware of regarding miscarriage?
    a. It is a natural pregnancy loss before labour begins.
    b. It occurs in fewer than 5% of all clinically recognized pregnancies.
    c. It often can be attributed to careless maternal behaviour, 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.

Answer 29

ANS: 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 labour, 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 10% to 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

Question 30

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

Answer 30

ANS: B
The laboratory results for disseminated intravascular coagulation include decreased fibrinogen and decreased platelets. Thrombocytopenia is a sign of pre-eclampsia. Bleeding time would be longer than 10 minutes in DIC.

Question 31

31. In caring for a patient immediately after they have given birth, a nurse notes petechiae and oozing from the patient’s IV site. The nurse would monitor them closely for which clotting disorder?
    a. Disseminated intravascular coagulation (DIC)
    b. Amniotic fluid embolism (AFE)
    c. Hemorrhage
    d. HELLP syndrome

Answer 31

ANS: A
DIC is an overactivation of the clotting cascade and the fibrinolytic system, resulting in depletion of platelets and clotting factors and therefore DIC results in a clinical picture of clotting, bleeding, and ischemia. HELLP syndrome includes hemolysis, elevated liver enzymes, and low platelets. Amniotic fluid embolism is not a clotting disorder.

Question 32

32. A labouring patient with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Their contractions are consistent with their current stage of labour. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. A nurse would suspect the patient has which condition?
    a. Placenta previa
    b. Vasa previa
    c. Severe placental abruption
    d. Disseminated intravascular coagulation (DIC)

Answer 32

ANS: B
A patient with placenta previa would have been diagnosed during routine ultrasound during pregnancy and would be considered high risk. Placental abruption is accompanied by pain and increased contraction pattern. DIC is a clotting disorder and would not cause a decreased fetal heart rate. Vasa previa is when fetal vessels lie over the cervical os. Usually, these vessels a re protected only by the membranes (not by Wharton’s jelly); thus they are at risk for rupture or compression. Vasa previa may be diagnosed when the membranes rupture and there is significant bleeding.

Question 33

33. In providing nutritional counselling for a pregnant patient experiencing cholecystitis, what would a nurse implement?
    a. Assess the patient’s dietary history for adequate calories and proteins.
    b. Teach the patient that the bulk of calories should come from proteins.
    c. Teach the patient to eat a low-fat diet and avoid fried foods.
    d. Teach the patient to eat a low-cholesterol, low-salt diet.

Answer 33

ANS: C
Teaching the patient to eat a low-fat diet and avoid fried foods is appropriate nutritional counselling for this patient. Caloric and protein intake do not predispose a patient to the development of cholecystitis. The patient should be instructed to limit protein intake and choose foods that are high in carbohydrates. A low-cholesterol diet may be the result of limiting fats. However, a low-salt diet is not indicated.

Question 34

34. An abortion in which the fetus dies but is retained within the uterus is called a(n)
    a. inevitable abortion.
    b. missed abortion.
    c. incomplete abortion.
    d. threatened abortion.

Answer 34

ANS: B
Missed abortion refers to 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 patient has cramping and bleeding but not cervical dilation.

Question 35

35. The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
    a. assess fetal heart rate (FHR) and maternal vital signs.
    b. perform a venipuncture for hemoglobin and hematocrit levels.
    c. place clean disposable pads to collect any drainage.
    d. monitor uterine contractions.

Answer 35

ANS: A
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 mother/fetal well-being. The blood levels can be obtained later. It is important to assess future bleeding; however, the top priority remains mother/fetal well-being. Monitoring uterine contractions is important but not the top priority.

Question 36

36. A patient with pregnancy-induced hypertension is admitted with symptoms of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs are an indication of
    a. anxiety due to hospitalization.
    b. worsening disease and impending convulsion.
    c. effects of magnesium sulfate.
    d. gastrointestinal upset.

Answer 36

ANS: B
Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. These are danger signs showing increased cerebral edema and impending convulsion and should be treated immediately. The patient has not been started on magnesium sulfate treatment yet. Also, these are not anticipated effects of the medication.

Question 37

37. A primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that
    a. bed rest and analgesics are the recommended treatment.
    b. they 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 major concern.

Answer 37

ANS: D
Severe bleeding occurs if the fallopian tube ruptures. The recommended treatment is to remove the pregnancy before rupture in order to prevent hemorrhaging. If the tube must be removed, the patient’s fertility will decrease; however, they will not be infertile. D&C is performed on the inside of the uterine cavity. The ectopic pregnancy is located within the tubes.

Question 38

38. A nurse caring for a patient hospitalized for hyperemesis gravidarum should expect that initial treatment to involve
    a. corticosteroids to reduce inflammation.
    b. IV therapy to correct fluid and electrolyte imbalances.
    c. an antiemetic, such as pyridoxine, to control nausea and vomiting.
    d. enteral nutrition to correct nutritional deficits.

Answer 38

ANS: B
Initially, the patient who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

Question 39

39. Screening at 24 weeks of gestation reveals that a pregnant patient has gestational diabetes mellitus (GDM). In planning their care, a nurse and the patient mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for
    a. macrosomia.
    b. congenital anomalies of the central nervous system.
    c. preterm birth.
    d. low birth weight.

Answer 39

ANS: A
Poor glycemic control later in pregnancy increases the rate of fetal macrosomia. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labour or birth is more likely to occur with severe diabetes and is the greatest risk in women with pregestational diabetes. Increased weight, or macrosomia, is the greatest risk factor for this patient.

Question 40

40. A patient with gestational diabetes has had little experience reading and interpreting glucose levels. They show a nurse their readings for the past few days. Based on the readings what information should the nurse provide to the patient?
    a. 4.2 mmol/L before lunch. This is low; better eat now.
    b. 6.0 mmol/L 1 hour after lunch. This is a little high; maybe eat a little less next
    time.
    c. 5.9 mmol/L 2 hours after lunch. This is too high; it is time for insulin.
    d. 3.5 mmol/L just after waking up in the morning. This is too low; maybe eat a
    snack before going to sleep.

Answer 40

ANS: D
3.5 mmol/L after waking is too low. During hours of sleep glucose levels should not be less than 3.8 mmol/L. Snacks before sleeping can be helpful. The premeal level is acceptable. The readings 1 hour after a meal should be between 5.5 and 7.7 mmol/L. Two hours after eating, the readings should be between 5.0 and 6.0 mmol/L.

Question 41

41. Which factor does a nurse know increases the risk of gestational diabetes mellitus?
    a. Underweight before pregnancy
    b. Maternal age younger than 25 years
    c. Previous birth of large infant
    d. Previous diagnosis of type 2 diabetes mellitus

Answer 41

ANS: C
Previous birth of a large infant suggests gestational diabetes mellitus. Obesity (BMI of 30 or greater) creates a higher risk for gestational diabetes. A woman younger than 25 years generally is not at risk for gestational diabetes mellitus. The person with type 2 diabetes mellitus already has diabetes and will continue to have it after pregnancy.

Question 42

42. What is the greatest risk for a fetus of a pregnant patient who has gestational diabetes mellitus (GDM)?
    a. Macrosomia
    b. Congenital anomalies of the central nervous system
    c. Postterm birth
    d. Low birth weight

Answer 42

ANS: A
Fetal macrosomia is a risk to the fetus of a mother with GDM. Poor glycemic control during the preconception time frame and into the early weeks of the pregnancy is associated with congenital anomalies. Preterm labour or birth is more likely to occur with severe diabetes, not postterm birth. Increased weight, or macrosomia, is the greatest risk factor for this woman.

Question 43

1. Which are bleeding disorders in late pregnancy? (Select all that apply.)
   a. Placenta previa
   b. Placental abruption
   c. Spontaneous abortion
   d. Vasa previa
   e. Velamentous insertion of the cord
   f. Eclampsia

Answer 43

ANS: A, B, D, E
Placenta previa is a cause of bleeding disorders in later pregnancy. Placental abruption is a cause of bleeding disorders in later pregnancy. Velamentous cord insertion is a cause of bleeding disorders in later pregnancy. Vasa previa is a cause of bleeding disorders in later pregnancy. Spontaneous abortion is another name for miscarriage; by definition it occurs early in pregnancy and is not considered a bleeding disorder. Eclampsia is a hypertensive disorder related to pregnancy.

Question 44

2. A patient who has undergone a dilation and curettage for early pregnancy loss is likely to be discharged the same day. Their vital signs are stable, bleeding has been controlled, and they have a low-normal hemoglobin level. To promote an optimal recovery, which should be part of discharge teaching for this patient? (Select all that apply.)
   a. Diet high in iron and protein
   b. Resumption of intercourse at 6 weeks following the procedure
   c. Can resume normal activity level with no restrictions
   d. Expectation of scant, dark discharge for 1 to 2 weeks
   e. Postpone pregnancy for at least 2 months
   f. Expectation of heavy bright red bleeding for 1 week

Answer 44

ANS: A,D,E
The patient should be advised to consume a diet high in iron and protein. For many patients iron supplementation also is necessary. Discharge teaching should emphasize the need for rest rather than an immediate return to normal activity level. 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 patient should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur, they should be instructed to contact their health care provider.

Question 45

As a result of the physiological alterations that accompany pregnancy, special considerations for mother and fetus are necessary when trauma occurs. Match the maternal system adaptation in pregnancy with the clinical response to trauma. Each answer can only be used one time.
Physiological alteration
a. Increased oxygen consumption
b. Increased heart rate
c. Decreased gastric motility
d. Displacement of abdominal viscera
e. Increase in clotting factors
Response to trauma
1. Decreased placental perfusion in supine position
2. Increased risk of thrombus formation
3. Altered pain referral
4. Increased risk of acidosis
5. Increased risk of aspiration

Answer 45

1. ANS: B
2. ANS: E
3. ANS: D
4. ANS: A
5. ANS: C