Nokea
The nurse is taking the health history of the 40-year-old pregnant client. Which identified medical conditions increase the client’s risk for complications during her pregnancy? Select all that apply.
- A. Diabetes mellitus type 2
- B. Previous full-term pregnancy
- C. Controlled chronic hypertension
- D. New onset of iron-deficiency anemia
- E. Hemorrhage with a previous pregnancy
Correct Answer: A,C,D,E
Rationale: DM is a risk factor for complications such as preeclampsia, eclampsia, dystocia, fetal macrosomia, recurrent monilial vaginitis and UTIs, ketoacidosis, congenital abnormalities, and others. Controlled chronic hypertension may become uncontrolled during pregnancy due to water retention and other factors related to pregnancy. It is a risk factor for complications such as preeclampsia, placental abruption, and fetal hypoxia. Iron-deficiency anemia is associated with an increased incidence of preterm birth, low-birth-weight infants, and maternal and infant mortality. Previous pregnancy complications are a risk factor for complications. Having a previous full-term pregnancy is not a risk factor for a current pregnancy.
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The nurse correctly explains that the bleeding is the result of sloughing of which structure?
- A. Endometrium
- B. Myometrium
- C. Epimetrium
- D. None of the above
Correct Answer: A
Rationale: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
The nurse is caring for the client with mild preeclampsia. The nurse should monitor for which complications associated with mild preeclampsia? Select all that apply.
- A. Placental abruption
- B. Hyperbilirubinemia
- C. Nonreassuring fetal status
- D. Severe preeclampsia
- E. Gestational diabetes
Correct Answer: A,B,C,D
Rationale: Placental abruption can occur as a complication of preeclampsia due to hypoperfusion of the placenta and endothelial injury. Hyperbilirubinemia can occur as a complication of preeclampsia due to hypoperfusion to the liver. Nonreassuring fetal status can occur as a complication of preeclampsia due to hypoperfusion to the placenta. Severe preeclampsia can occur as a complication of preeclampsia if the BP remains uncontrolled. Gestational diabetes is not associated with preeclampsia.
The nurse identifies which sign as indicative of postpartum depression?
- A. Occasional mood swings
- B. Persistent feelings of hopelessness
- C. Excitement about motherhood
- D. Increased energy levels
Correct Answer: B
Rationale: Persistent feelings of hopelessness are a key indicator of postpartum depression, requiring intervention.