Exam 2 (NUR 353) | Questions and Answers (Complete Solutions)

Exam 2 (NUR 353) | Questions and Answers (Complete Solutions) A nurse is assessing a patient with preeclampsia who delivered 12 hours ago. Which of the following assessments would indicate that the condition has not yet resolved? a. blood pressure reading at prenatal baseline b. adequate urinary output and no proteinuria c. presence of 1-2+ deep tendon reflexes d. patient complaints of blurred vision and headache A nurse is completing the admission assessment of a client who is at 38 weeks gestation and has severe preeclampsia. Which one of the following findings is consistent with the diagnosis of severe preeclampsia? a. Polyuria b. Absence of clonus c. Epigastric pain d. Tachycardia Why is magnesium sulfate is given to women with preeclampsia and eclampsia? a. To improve patellar reflexes and increase respiratory efficiency b. To prevent and treat convulsions c. To decrease blood pressure readings d. To prevent a boggy uterus and lessen lochial flow A nurse in a prenatal clinic is reviewing results from recent one-hour oral glucose tolerance tests. Which one of the 4 pregnant clients needs to be scheduled for a follow-up, diagnostic three-hour glucose tolerance test? a. One hour GTT result: 115 mg/dl b. One hour GTT result: 95 mg/dl c. One hour GTT result: 125 mg/dl d. One hour GTT result: 160 mg/dl A nurse is caring for a client at 30 weeks gestation who has just been diagnosed with gestational diabetes. The client has a lot of questions about the risks to her baby with GDM. What is the best explanation by the nurse for why her fetus is at risk for macrosomia and hypoglycemia at delivery? a. To prevent macrosomia, you should only gain 11-20 lbs. total during this pregnancy. b. When your blood sugar levels are too high, the insulin that you make can cross the placenta and affect your baby's metabolism. c. Extra sugar (glucose) can cross the placenta to your baby. This may cause your baby to gain extra weight and to have sudden low blood glucose after birth. d. Your baby may be born with diabetes. What are three classic clinical manifestations of preeclampsia? 1. Proteinuria 2. Epigastric pain 3. Headaches In a normal pregnancy, spiral arteries widen to improve perfusion to the placenta. In a preeclamptic pregnancy, the spiral arteries do widen, but not nearly as much which decreases blood flow to the placenta. Your brain perceives hypo perfusion, and your brain thinks that you are bleeding out. Your brain is going to release vasoconstrictor hormones and try to redirect that blood to vital organs, such as the heart, brain, lungs, etc. Your brain doesn't think of the baby as a vital organ. This vasoconstriction leads to an increase in blood pressure. Over time, this increase in BP causes wear and tear in your blood vessels, leading to little holes in the vessels. Your brain stimulates a lipoprotein to be released to try to repair the vessels, but they are not able to. The lipoprotein leaks out from the vessels and into the intravascular space. The proteins attract water which causes edema. Liver necrosis can occur long term due to the initiation of the clotting cascade by the brain, causing hypoxia, then ischemia, then necrosis. Pathophysiology of preeclampsia. Hypertensive disorder of pregnancy whereby the woman has an elevated blood pressure at 140/90 mmHg or greater recorded on two different occasions at least 4 hours apart. Proteinuria is absent. Gestational hypertension This occurs when expulsion of the products of conception occurs. Premature cervical dilations. A cause of bleeding during pregnancy. Cervical insufficiency What length is considered a short cervix? Less than 25 mm in length True or false. Dehydration stimulates uterine contractions. True Client education for a pregnant woman experiencing cervical insufficiency. (3) 1. Client will be on activity restriction or bed rest. 2. Hydrate more, because dehydration stimulates uterine contractions. 3. Avoid intercourse, tampons, and douching. Anything that can be inserted into the vagina. List two risk factors for cervical insufficiency. 1. History of cervical trauma (Cervical tears, excessive dilations, surgical procedures.) 2. Congenital structural defects List four expected findings for cervical insufficiency. 1. Increase in pelvic pressure or urge to push. 2. Pink stained vaginal discharge or bleeding 3. Water may break 4. Miscarriage (Uterus contracts with the expulsion of the fetus) Presence of cervical funneling Beaking Gestational diabetes mellitus (GDM) An impaired tolerance to glucose with the first onset or recognition during pregnancy. List four laboratory tests conducted on a pregnant woman who is suspected to have GDM. 1. Routine urinalysis to test for glycosuria 2. 1 hour GTT 3. 3 hour oral GTT 4. Urinalysis to test for presence of ketones in urine List three interventions for a patient who is experiencing gestational hypertension. 1. Antihypertensive medications 2. Diet 3. Exercise What alteration in deep tendon reflexes is manifested in preeclampsia? Hyperreflexia What level is a positive 1-hour GTT? Over 140 mg/dL Do you have to fast for a 1-hour GTT? No, but you do have to fast for a 3-hour GTT. List three things you cannot do before a 3-hour GTT. 1. No eating 12 hours before test. 2. Do not drink caffeine. 3. Do not smoke 12 hr prior to testing. What are three diagnostic procedures that would be conducted on a patient with GDM to assess fetal well-being? 1. BPP 2. Amniocentesis 3. NST If a woman is diagnosed with GDM, what is the first pt. education provided to help treat this? Diet and exercise. If glucose levels are persistently high, insulin or oral hypoglycemia therapy is begun. Gestational hypertension begins after the ____ week of pregnancy. 20th Gestational hypertension (140/90) with the addition of proteinuria of greater than or equal to 1+. Report of transient headaches might occur along with episodes or irritability. Edema can be present. Mild preeclampsia. Consists of BP that is 160/110 mmHg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia. Severe preeclampsia Severe preeclamptic manifestations with the onset of seizure activity or coma. Eclampsia Describe HELLP. H: Hemolysis resulting in anemia and jaundice. EL: Elevated liver enzymes, such as ALT, AST, including epigastric pain and nausea and vomiting. LP: Low platelets (Less than 100,000/mm3), resulting in thrombocytopenia. Results in reduced clotting factors, causing manifestations such as bleeding gums. List 7 risk factors related to gestational hypertensive disorders. 1. Abnormal maternal age (19 or 40) 2. Prima gravida 3. Obesity 4. Having multiple fetuses 5. Chronic hypertension 6. Family history of preeclampsia 7. Having DM What type of stomach pain is experienced in preeclampsia? Epigastric pain with right upper quadrant pain What 3 diagnostic procedures are conducted to test for gestational hypertensive disorders? 1. Urine testing for proteinuria and creatinine clearance. 2. NST, CST, and BPP to assess fetal status 3. Doppler blood flow analysis to assess fetal well-being Medication of choice to prevent seizures in the client who has eclampsia and severe preeclampsia. Magnesium sulface List 5 manifestations of magnesium sulfate toxicity. 1. Absence of patellar deep tendon reflexes. 2. Urine output less than 30 mL/hr 3. RR less than 12/min 4. Decreased LOC 5. Cardiac dysrhythmias What is the antidote for magnesium sulfate? Calcium gluconate A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) a. RR less than 12/min b. Urinary output less than 30 mL/hr c. Hyperreflexic deep-tendon reflexes d. Decrease LOC e. Flushing and sweating List 6 client education points for managing gestational hypertensive disorders postpartum. 1. Maintain bed rest and encourage side-lying position. 2. Promote diversional activities, such as watching TV, visits from family or friends, and gentle exercise 3. Avoid foods that are high in sodium 4. Avoid alcohol, tobacco, and caffeine intake 5. Drink 6-8 glasses of water a day 6. Maintain a dark environment to prevent seizures Magnesium sulfate toxicity can cause what serious adverse effect? Coma How many values in the 3-hour GTT must be elevated for there to be a diagnosis of gestational diabetes mellitus? 2 out of the 3 What levels should pregnant women keep their blood sugar between? What should they keep their postprandial BG levels less than? 65 to 95 mg/dL. 130 mg/dL. This occurs when a fertilized ovum is implanted outside the uterus. 95% of these occur in the fallopian tube. Characterized by unilateral lower-quadrant abdominal pain with or without vaginal bleeding. Ectopic pregnancy (tubal pregnancy) A cervix that opens without contractions which can cause a preterm labor or birth. The cervix is too short. We don't want it to open early because that keeps the baby inside the uterus. Vaginal bleeding can occur. We can stitch the cervix closed until she is past the risk of going into preterm labor. Incompetent cervix/cervical insufficiency A problem with the fertilization of the ovum. Two sperm try to fertilize themselves which forms a ball of cells, there is no viable fetus. A woman does miss her period, her fundal height will be very large, she will have some sort of vaginal bleeding, these molar pregnancy cells grow very fast. Methotrexate is used to stop them from growing. Hydatidiform mole (molar pregnancy) Four causes of early pregnancy bleeding (20 weeks). 1. Miscarriage 2. Ectopic pregnancy 3. Incompetent cervix 4. Hydatidiform mole Two causes of bleeding later in pregnancy. 1. Placenta previa 2. Placental abruption This complication of pregnancy is characterized by bright red painless bleeding. It begins at the beginning of pregnancy but occurs when the placenta forms near the cervix. Placenta previa Patient education for a client with placenta previa. You cannot have intercourse, insert tampons, or put anything in the vagina. No vaginal exams may be conducted by the provider or nurse. You will have a C-section. Placenta is in right place but because of different factors such as preeclampsia or drug abuse, a collection of blood forms near the placenta. Premature separation of the placenta. Vaginal bleeding and complaining of severe abdominal pain. Uterine tenderness and sometimes a board like uterus. Placenta abruption List at least 5 risk factors associated with miscarriages. (There are 9) 1. Chromosomal abnormalities 2. Maternal illness 3. Advanced maternal age 4. Premature cervical dilation (Cervical insufficiency) 5. Chronic maternal infections 6. Maternal malnutrition 7. Trauma or injury 8. Anomalies in the fetus or placenta 9. Substance use List at least 3 expected findings associated with a miscarriage. (There are 6) 1. Backache and abdominal tenderness 2. Rupture of membranes 3. Dilation of the cervix 4. Fever 5. Hypotension 6. Tachycardia Client education for a patient that has just had a miscarriage. 1. Notify provider of heavy, bright red vaginal bleeding, elevated temperature, or foul smelling vaginal discharge 2. A small amount of discharge is normal for 1-2 weeks 3. Take prescribed antibiotics 4. Refrain from tub baths, sexual intercourse, or placing anything into the vagina for 2 weeks 5. Avoid becoming pregnant for 2 months List 5 clinical findings associated with ectopic pregnancy. 1. Unilateral stabbing pain and tenderness in the lower-abdominal quadrant 2. Scant, dark red, or brown vaginal spotting 3. Faintness and dizziness 4. Hypotension 5. Tachycardia, pallor First and most important nursing care associated with an ectopic pregnancy. Replace fluids, and maintain electrolyte balance The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? a. "I will not experience mood swings since I was only at 10 weeks of gestation." b. "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." c. "I should eat foods that are high in iron and protein to help my body heal." d. "I should expect the bleeding to be heavy and bright red for at least 1 week." (After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider.) A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: a. a sleepy, sedated affect. b. a respiratory rate of 10 breaths/min. c. deep tendon reflexes of 2+. d. absent ankle clonus. (Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.) A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: a. blood pressure is reduced to prepregnant baseline. b. seizures do not occur. c. deep tendon reflexes become hypotonic. d. diuresis reduces fluid retention. (A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.) A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: a. hydralazine. b. magnesium sulfate bolus c. diazepam. d. calcium gluconate. (Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.) The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: a. bleeding. b. intense abdominal pain. c. uterine activity. d. cramping. (Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions.) A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: a. eclamptic seizure. b. rupture of the uterus. c. placenta previa. d. placental abruption. (Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.) Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? a. Prepare the woman for a dilation and curettage (D&C). b. Place the woman on bed rest for at least 1 week and reevaluate. c. Prepare the woman for an ultrasound and blood work. d. Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month. (D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.) A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for: a. hemorrhage. b. infection. c. urinary retention. d. thrombophlebitis. (Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta.) The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply.) a. Decreased urinary output and irritability b. Transient headache and +1 proteinuria c. Ankle clonus and epigastric pain d. Platelet count of less than 100,000/mm3 and visual problems e. Seizure activity and hypotension (Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.) A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: