The Client with an Ectopic Pregnancy

73.

1. The client’s signs and symptoms indicate a probable ectopic pregnancy, which can be confi rmed by ultrasound examination or by culdocentesis. The physician is notifi ed immediately because hypov- olemic shock may develop without external bleed- ing. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board-like uterus in the third trimester. Gestational trophoblas- tic disease would be suspected if the client exhib- ited no fetal heart rate and symptoms of pregnancy- induced hypertension before 20 weeks’ gestation.

A client with a complete abortion would exhibit a normal pulse and blood pressure with scant vaginal bleeding.

CN: Physiological adaptation;

CL: Analyze

74.

1, 2, 3, 5, 6. The client may be experienc- ing an ectopic pregnancy. Contributing factors to an ectopic pregnancy include a prior history of sexually transmitted infection which can scar the fallopian tubes. Prior use of an IUD as contracep- tion with multiple sex partners increases the risk of sexually transmitted infections. Knowledge of the client’s last menstrual period and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client’s history of cesarean sections would not contribute information valuable to the client’s current situation or potential diagnosis of ectopic pregnancy.

CN: Reduction of risk potential;

CL: Analyze

75.

2. Falling hematocrit and hemoglobin levels indicate shock, which occurs if the tube ruptures.

Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain and referred shoulder pain. The amount of vaginal bleeding that is evident is a poor estimate of ac- tual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready

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pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdomi- nal edema is a late sign of a tubal rupture in ectopic pregnancy.

CN: Reduction of risk potential;

CL: Analyze

76.

4. Fallopian tube rupture is an emergency situation because of extensive bleeding into the peri- toneal cavity. Shock soon develops if precautionary measures are not taken. The nurse readying a client for surgery should be especially careful to monitor blood pressure and pulse rate for signs of impending shock. The nurse should be prepared to administer fl uids, blood, or plasma expanders as necessary through an intravenous line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely.

However, abdominal tenderness or knife-like pain may occur. Abdominal fullness may be present, but abdominal distention is rare unless peritonitis has developed. Although the hemoglobin and hemat- ocrit may be checked routinely before surgery, the laboratory results may not truly refl ect the presence or degree of acute hemorrhage.

CN: Reduction of risk potential;

CL: Analyze

77.

3. Anything that causes a narrowing or con- striction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy.

Pelvic infl ammatory disease is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to urinary tract infections. Use of marijuana during pregnancy is not associated with ectopic pregnancy, but its use can result in cognitive reduction if the mother’s use during pregnancy is extensive. Progestin-only contraceptives and intra- uterine devices have been associated with ectopic pregnancy.

CN: Physiological adaptation;

CL: Analyze

78.

2. The client should not experience a head- ache or dizziness. Symptoms that the client should report include pain (caused by stretching of the tube), temperature elevation (suggesting infection), and bleeding (suggesting hemorrhage). The client should also be instructed that infertility may occur as a result of the removal of one fallopian tube.

CN: Reduction of risk potential;

CL: Evaluate

79.

3. Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This chemotherapeutic agent attacks the

fast-growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestin-only contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used.

CN: Pharmacological and parenteral therapies; CL: Analyze

The Pregnant Client with Hyperemesis Gravidarum

80.

3. The client needs further instructions when she says she should eat two meals a day with frequent protein snacks to decrease nausea and vomiting. The client should eat more frequent, smaller meals, with frequent carbohydrate snacks to decrease nausea and vomiting. Eating dry crackers or toast before arising, consuming fl uids separately from meals, and avoiding greasy or spicy foods may also help to decrease nausea and vomiting.

CN: Basic care and comfort; CL: Evaluate

81.

3. Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspi- ration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine.

Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocal- cemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyper- emesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fl uids, decreased metabolism of nutrients, and excessive vomiting.

CN: Reduction of risk potential;

CL: Analyze

82.

2. Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotrophin production.

Hyperemesis is also associated with infectious con- ditions, such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole.

Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.

CN: Physiological adaptation; CL: Apply

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83.

25 gtts/minute

Gtts 12 gtts 1000 mL 1 hr

25 gtts/min min = 1 mL ´ 8 hr ´60 min=

CN: Pharmacological and parenteral therapies; CL: Apply

84.

3. The client usually remains NPO for 24 hours after initiation of IV fl uid replacement thera- py. If the client is not vomiting after 24 hours, HCP orders generally allow for clients to be started on clear liquids. If the client tolerates liquids, then dry toast, crackers, or cereal may be given every 2 to 3 hours. The client should be given a choice of foods.

The temperature of the foods and fl uids should be appropriate (i.e., hot food served hot, cold foods served cold). Total parenteral nutrition is initiated only if other measures, such as IV fl uid replacement and pharmacologic care, fail.

CN: Physiological adaptation; CL: Create

The Client with a Hydatidiform Mole

85.

4. The nurse should prepare the client for an ultrasound to determine the cause of the symptoms.

Elevated blood pressure at this point in the preg- nancy could indicate chronic hypertension as well as hydatidiform mole. The fundal height of 19 cm is higher than is typically found at 15 weeks’ gestation and is indicative of a molar pregnancy (hydatidi- form mole). The dark brown vaginal bleeding in iso- lation could indicate an abortion but when placed in context of the other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal at this point in the pregnancy and can be a result of the high levels of progesterone from a molar pregnancy. There is no fetus involved;

the blood pressure elevation and the continuous nausea and vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status.

CN: Reduction of risk potential;

CL: Synthesize

86.

1. Hydatidiform mole is suspected when the following are present: pregnancy-induced hyperten- sion before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gesta- tional age, and increased human chorionic gonado- trophin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs

occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from car- diac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies.

CN: Reduction of risk potential;

CL: Analyze

87.

2. After D&C to evacuate a molar pregnancy, the nurse should assess the client’s vital signs and monitor for signs of hemorrhage, because the surgi- cal procedure may have traumatized the uterine lin- ing, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molar pregnancy, are most commonly related to urinary catheteriza- tion. Typically, urinary catheters are not used during evacuation of a molar pregnancy. The client should not experience abdominal distention, because the contents of the uterus have been removed. Chorio- amnionitis is an infl ammation of the amniotic fl uid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.

CN: Reduction of risk potential;

CL: Analyze

88.

2. A client who has had a hydatidiform mole removed should have regular checkups to rule out the presence of choriocarcinoma, which may complicate the client’s clinical picture. The client’s human chorionic gonadotropin (hCG) levels are monitored for 1 year. During this time, she should be advised not to become pregnant because this would be refl ected in rising hCG levels. Ectopic or multifetal pregnancy is not associated with hyda- tidiform mole. Women who have molar pregnancies have fertility rates similar to the general population.

CN: Reduction of risk potential;

CL: Synthesize

89.

2. A client who has experienced a molar pregnancy is at risk for development of choriocar- cinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradu- ally begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrex- ate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.

CN: Reduction of risk potential;

CL: Apply

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The Pregnant Client with Miscellaneous Complications

90.

4. Herpes simplex virus can be transmitted to the infant during a vaginal delivery. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can deliver vagi- nally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months’ gestation, the breech position is not a concern.

CN: Physiological adaptation; CL: Evaluate

91.

2. Ask staff to activate emergency response system.

1. Open airway using head tilt-chin lift.

4. Give 2 breaths.

5. Check the pulse

3. Establish unresponsiveness.

The client’s actions indicate distress and the nurse should initiate emergency procedures. The nurse should fi rst establish unresponsiveness and then ask staff to activate the emergency response system.

Next, the nurse should assure an open airway and then give 2 breaths. The nurse should then check the carotid pulse, and if necessary begin chest com- pressions.

CN: management of care; CL: Synthesize

92.

4. Sickle cell disease is an autosomal reces- sive disorder requiring both parents to have a sickle cell trait to pass the disease to a child. Deoxygenated hemoglobin cells assume a sickle shape and ob- struct tissues. Tissue obstruction causes hypoxia to the area (vasoocclusion) and results in pain, called sickle cell crisis. This type of anemia is an inherited disorder; it is not caused by lack of iron in the diet.

Self-monitoring for any type of infections or sickle cell crisis and increased frequency of antenatal care visits are part of the teaching plan of care.

CN: Physiological adaptation;

CL: Evaluate

93.

1. The nurse should place a hand on the fetal head and provide gentle upward pressure to re- lieve the compression on the cord. Doing so allows oxygen to continue fl owing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother but, until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression.

CN: management of care; CL: Synthesize

94.

1, 2, 3, 4. Having the fetus at a negative sta- tion places the client at risk for a cord prolapse.

With a negative station, there is room between the fetal head and the maternal pelvis for the cord to slip through. A small infant is more mobile within the uterus and the cord can rest between the fetus and the inside of the uterus or below the fetal head.

With a large infant, the head is usually in a vertex presentation and occludes the lower portion of the uterus, preventing the cord from slipping by. When membranes rupture, the cord can be swept through with the amniotic fl uid. In a breech presentation, the fetal head is in the fundus and smaller portions of the fetus settle into the lower portion of the uterus, allowing the cord to lie beside the fetus. Prior abor- tion and a low lying placenta have no correlation to cord prolapse.

CN: Physiological adaptation;

CL: Analyze

95.

3. A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fi st or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum.

CN: Health promotion and maintenance;

CL: Create

96.

2. RhoGAM is given to new mothers who are Rh-negative and not previously sensitized and who have delivered an Rh-positive infant. RhoGAM must be given within 72 hours of the delivery of the in- fant because antibody formation begins at that time.

The vaccine is used only when the mother delivered an Rh-positive infant—not an Rh-negative infant.

RhoGAM does not prevent German measles and is not given to a newborn.

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CN: Pharmacological and parenteral therapies; CL: Evaluate

97.

2. The client is experiencing and verbalizing signs of postpartum depression, which usually ap- pears at about 4 weeks postpartum but can occur at any time within the fi rst year after birth. It is more severe and lasts longer than postpartum blues, also called “baby blues.” Baby blues are the mildest form of depression and are seen in the later part of the fi rst week after birth. Symptoms usually disappear shortly. Depression may last several years and is disabling to the woman. Poor bonding may be seen at any time but commonly becomes evident as the mother begins interacting with the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A depressed mother is at risk for injuring or abusing her infant.

CN: Reduction of risk potential;

CL: Synthesize

98.

2, 3, 7. The nursing assistant could assist the client with breathing and relaxation, and ambulate the postcesarean client to the bathroom. Remov- ing lunch trays and adding the intake to the input and output sheet is a nursing assistant responsibil- ity. Removing a Foley catheter would also involve assessment of bladder status and totaling the intake and output and would be a nursing responsibil- ity. Calculating the hourly I.V. totals for a preterm labor client would involve assessments that require nursing expertise. In-and-out catheterization, a sterile procedure, and calling reports to health care providers, which requires gathering and analysis of data, are responsibilities of the nurse.

CN: Management of care; CL: Evaluate

Managing Care Quality and Safety

99.

3. A preeclamptic client with +3 proteinuria and epigastric pain is at risk for seizing, which would jeopardize the mother and the fetus. Thus, this client would be the highest priority. The client at 13 weeks’

gestation with nausea and vomiting is a concern be- cause the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the insulin-dependent diabetic. The insulin- dependent diabetic is a high priority; however, fetal movement indicates that the fetus is alive but may be ill. As few as four fetal movements in 12 hours can be considered normal. (The client may need ad- ditional testing to further evaluate fetal well-being.) The primigravida who is at 17 weeks’ gestation is too early in her pregnancy to experience fetal movement and would be the last person to be seen.

CN: Management of care; CL: Evaluate

100.

3. The nurse should refer the client who is preeclamptic client with 3+ proteinuria to a health care provider. The 3+ urine is signifi cant, indicating there is much protein circulating. The woman who is 37 weeks’ gestation with insulin-dependent diabetes who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tab- lets until the client can obtain an appointment with the care provider. The client at 10 weeks’ gestation with nausea and vomiting and + 1 ketones should also be seen by a health care provider, but at this point this client is uncomfortable but her life is not in danger. The 15-week primigravid client will not be feeling her baby move this soon in the pregnancy and this would not be considered a problem that requires immediate referral to a health care provider.

CN: Management of care; CL: Evaluate

101.

2. Assess the client’s current status 1. Notify the physician of the incident.

4. Initiate an incident report.

3. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.

The nurse should fi rst change the I.V. magnesium sul- fate and normal saline infusion rates, and then assess the current status of the client. The nurse should then notify the physician to explain the error and, report the action taken. A medication error has occurred and the nurse will need to initiate an incident report.

CN: Management of care; CL: Synthesize

102.

3. Maintain airway.

2. Turn the client to her side.

4. Note the length of time of seizure.

1. Call for immediate assistance.

If a client begins to have a seizure, the fi rst action by the nurse is to remain with the client and call for immediate assistance. Next, the nurse should turn the client to her side and then maintain the airway by keeping the neck hyperextended. Noting the length of the seizure and the limb involvement are observations that are ongoing.

CN: Management of care; CL: Synthesize

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