High-Risk Disorders

Question 1

What instructions should the nurse give the woman with a threatened abortion?

Answer 1

Maintain strict bed rest for 24 to 48 hours. Avoid sexual intercourse for 2 weeks.

Question 2

Identify the nursing plans and interventions for a woman hospitalized with hyperemesis gravidarum.

Answer 2

• Weigh daily
• Check urine ketone three times daily
• Give progressive diet
• Check FHR every 8 hours
• Monitor for electrolyte imbalances

Question 3

Describe discharge counseling for a woman after hydratiform mole evacuation by D&C.

Answer 3

Prevent pregnancy for 1 year. Return to clinic or MD for monthly hCG levels for 1 year. Postoperative D&C instructions: Call if bright-red vaginal bleeding or foul-smelling vaginal discharge occurs or temperature spikes over 100.4F

Question 4

What condition should the nurse suspect if a woman of childbearing age presents to an emergency room with bilateral or unilateral abdominal pain, with or without bleeding?

Answer 4

Ectopic pregnancy

Question 5

List three symptoms of abruptio placentae and three symptoms of placenta previa.

Answer 5

• Abrupto placentae: fetal distress; rigid, boardlike abdomen; pain; dark-red or absent bleeding
• Previa: pain-free; bright-red vaginal bleeding; normal FHR; soft uterus

Question 6

What specific information should the nurse include when teaching about HPV detection and treatment?

Answer 6

Detection of dry, wartlike growths on vulva or rectum. Need for Pap smear in the prenatal period. Treatment with later ablation (cannot use podophyllin during pregnancy). Associated with cervical carcinoma in mother and respiratory papillomatosis in neonate. Teach about immunization for females age 9 to 30 with Gardasil.

Question 7

State three principles pertinent to counseling and teaching a pregnant adolescent.

Answer 7

Nurse must establish trust and rapport before counseling and teaching begin. Adolescents do not respond to an authoritarian approach. Consider the developmental tasks of identity and social and individual intimacy.

Question 8

What complications are pregnant adolescents particularly prone to develop.

Answer 8

Preeclampsia, IUGR, CPD, STDs, anemia

Question 9

All pregnant women should be taught preterm labor recognition. Describe the warning symptoms of preterm labor.

Answer 9

More than five contractions per hour; cramps; low, dull backache; pelvic pressure; change in vaginal discharge

Question 10

List the factors predisposing a woman to perterm labor.

Answer 10

Urinary tract infection; overdistention of uterus; diabetes; preeclampsia; cardiac disease; placenta previa; psychosocial factors such as stress

Question 11

When is preterm labor able to be arrested?

Answer 11

Cervix is <50% effacement, and membranes are intact and not bulging out of the cervical os.

Question 12

What is the major side effect of beta-adrenergic tocolytic drugs (Terbutaline)?

Answer 12

Tachycardia

Question 13

What special actions should the nurse take during the intrapartum period if preterm labor is unable to be arrested?

Answer 13

Monitor the FHR continuously and limit drugs that cross placental barriers so as to prevent fetal depression or further compromise.

Question 14

A prolonged latent phase for a multipara is ___ and for a nullipara is ___. Multiparas’ average cervical dilation is ___ cm/hr in the active phase, and nulliparas’ average cervical dilation is ____ cm/hr in the active phase.

Answer 14

> 14 hours. .20 hours. 1.5, 1.2

Question 15

What are the major goals of nursing care related to pregnancy-induced hypertension with preeclampsia?

Answer 15

Maintenance of uteroplacental perfusion; prevention of seizures; prevention of complications such as HELLP syndrome, DIC, and abruption

Question 16

Magnesium sulfate is used to treat preeclampsia.

A. What is the purpose of administering magnesium sulfate?
B. What is the main action of magnesium sulfate?
C. What is the antidote for magnesium sulfate?
D. List the three main assessment findings indicating toxic effects of magnesium sulfate

Answer 16

A. To prevent seizures by decreasing CNS irritability
B. CNS depression (seizure prevention)
C. Calcium gluconate
D. Reduced urinary output, reduced respiratory rate, and decreased reflexes

Question 17

What are the major symptoms of preeclampsia?

Answer 17

Increase in BP of 30 mm Hg systolic and 15 mm Hg diastolic over previous baseline; proteinuria (albuminuria); CNS disturbances

Question 18

What is the priority nursing action after spontaneous or AROM?

Answer 18

Assessment of the FHR

Question 19

What is the most common complication of oxytocin augmentation or induction of labor? List three actions the nurse should take if such a complication occurs.

Answer 19

Tetany. Turn off Pitocin. Turn pregnant woman onto side. Administer O2 by mask.

Question 20

List the symptoms of water intoxication resulting from the effect of Pitocin (oxytocin) on the antidiuretic hormone (ADH).

Answer 20

Nausea and vomiting, headache, and hypotension

Question 21

State three nursing interventions during forceps delivery.

Answer 21

Ensure empty bladder: Auscultate FHR before application, during process, and between traction periods. Observe for maternal lacerations and newborn cerebral or facial trauma.

Question 22

What is the cause of preeclampsia?

Answer 22

The person who determines the exact cause will be our next Nobel Prize winner! However, the underlying pathophysiology appears to be generalized vasospasm with increased peripheral resistance and vascular damage. This decreased perfusion results in damage to numerous organs.

Question 23

What interventions should the nurse implement to prevent further CNS irritability in the preeclampsia client?

Answer 23

Darken room, limit visitors, maintain close 1:1 nurse-to-client ratio, place in private room, plan nursing interventions at all the same time so client is disturbed as little as possible.

Question 24

A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this medication during pregnancy. How should the nurse respond?

Answer 24

No. Oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.

Question 25

Name three maternal and three fetal complications of gestational diabetes.

Answer 25

Maternal: hypoglycemia, hyperglycemia, ketoacidosis

Fetal: macrosomia, hypoglycemia at birth, fetal anomalies

Question 26

When should the nurse hold the dose of magnesium sulfate and call the physicial?

Answer 26

When the client’s respirations are <100 mL/4 hr

Question 27

State three priority nursing actions in the postdelivery period for the client with preeclampsia.

Answer 27

Monitor for signs of blood loss. Continue to assess BP and DTRs every 4 hours. Monitor for uterine atony.

Question 28

What are the two most difficult times for control in the pregnant diabetic?

Answer 28

Late in the third trimester and in the postpartum period, when insulin needs drop sharply (the diabetogenic effecs of pregnancy drop sharply (the diabetogenic effects of pregnancy drop precipitously)

Question 29

Why is regular insulin used in labor?

Answer 29

It is short-acting, predictable, can be infused intravenously, and can be discontinued quickly if necessary

Question 30

List three conditions clients with diabetes mellitus are more prone to develop.

Answer 30

Preeclampsia, hydraminos, infection

Question 31

When is cardiac disease in pregnancy most dangerous?

Answer 31

At peak plasma volume increase, between 28 and 32 weeks’ gestation, and during stage II labor

Question 32

Does insulin cross the placenta-breast barrier?

Answer 32

No. Therefore, insulin-dependent women may breastfeed.

Question 33

The goal for diabetic management during labor is euglycemia. How is it defined?

Answer 33

70 to 90 mg/dL

Question 34

What contraceptive technique is recommended for diabetic women?

Answer 34

Diaphragm with spermicide; clients should avoid birth control pills, which contain estrogen, and IUDs, which are an infection risk

Question 35

List the symptoms of cardiac decompensation in a laboring client with cardiac disease.

Answer 35

Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea

Question 36

What interventions can the nurse implement to maintain cardiac perfusion in a laboring cardiac client?

Answer 36

Position client in a semi-or high Fowler. Prevent Valsalva maneuvers. Position client in a side-lying position for regional anesthesia. Avoid stirrups because of possible popliteal vein compression and decreased venous return.

Question 37

Gentle counterpressure against the perineum during an emergency delivery prevent ___ and ___.

Answer 37

Maternal laceration, fetal cerebral trauma

Question 38

When may a VBAC be considered by a woman with a previous cesarean section?

Answer 38

If a low uterine transverse incision was performed and can be documented and if the original complication does not recur, such as CPD.

Question 39

Prior to anesthesia for cesarean section delivery, the motor may be given an antacid or a gastric antisecretory drug (histamine receptor antagonist). State the reasons these drugs are given.

Answer 39

Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues. An antisecretory drug reduces gastric acid, reducing the risk for gastric aspiration.

Question 40

Clients who have had a cesarean section are prone to what postoperative complications?

Answer 40

Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired maternal-infant bonding,