Chapter 28: Antepartum Hemorrhagic Disorders My Nursing Test Banks

Lowdermilk: Maternity & Womens Health Care, 10th Edition

Chapter 28: Antepartum Hemorrhagic Disorders

Test Bank

MULTIPLE CHOICE

1. A pregnant woman is being discharged from the hospital after placement of a cerclage because of a history of recurrent pregnancy loss secondary to an incompetent cervix. Discharge teaching should emphasize that:

a.

Any vaginal discharge should be reported immediately to her health care provider

b.

The presence of any contractions, rupture of membranes or severe perineal pressure should be reported

c.

She will need to make arrangements for care at home, because her activity level will be restricted

d.

She will be scheduled for a cesarean birth

ANS: B

Nursing care should stress the importance of monitoring signs and symptoms of preterm labor.

Vaginal bleeding needs to be reported to her primary health care provider.

Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the womans need for visits and to safely monitor her status at home.

The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned.

DIF: Cognitive Level: Application REF: 676

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning, Implementation

2. A perinatal nurse is giving discharge instructions to a woman, status post suction and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is:

a.

If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available.

b.

The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult.

c.

If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time.

d.

Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy.

ANS: B

Beta-hCG levels are drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a zero hCG level. If the woman were to become pregnant, it may 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 carcinogenic cells are not present.

Any contraceptive method except an intrauterine device (IUD) is acceptable.

DIF: Cognitive Level: Application REF: 680

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Implementation

3. Methotrexate is recommended as part of the treatment plan for which obstetric complication?

a.

Complete hydatidiform mole

b.

Missed abortion

c.

Unruptured ectopic pregnancy

d.

Abruptio placentae

ANS: C

Methotrexate is an effective nonsurgical treatment option for a hemodynamically stable woman whose ectopic pregnancy is unruptured and less than 4 cm in diameter.

Methotrexate is not indicated or recommended as a treatment option for a complete hydatidiform mole.

Methotrexate is not indicated or recommended as a treatment option for missed abortions.

Methotrexate is not indicated or recommended as a treatment option for abruptio placentae.

DIF: Cognitive Level: Knowledge REF: 677

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

4. A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what will be the diagnostic procedure?

a.

Amniocentesis for fetal lung maturity

b.

Ultrasound for placental location

c.

Contraction stress test (CST)

d.

Internal fetal monitoring

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 is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother given corticosteroids to aid in fetal lung maturity.

A CST is not performed at a preterm gestational age. Furthermore, bleeding is a contraindication to this test.

Internal fetal monitoring is contraindicated in the presence of bleeding.

DIF: Cognitive Level: Application REF: 680, 681

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

5. A laboring woman with no known risk factors suddenly experiences spontaneous rupture of membranes (ROM). The fluid consists of bright red blood. Her contractions are consistent with her current stage of labor. There is no change in uterine resting tone. The fetal heart rate begins to decline rapidly after the ROM. The nurse should suspect the possibility of:

a.

Placenta previa

b.

Vasa previa

c.

Severe abruptio placentae

d.

Disseminated intravascular coagulation (DIC)

ANS: B

Vasa previa is the result of a velamentous insertion of the umbilical cord. The umbilical vessels are not surrounded by Wharton jelly and have no supportive tissue. The umbilical blood vessels thus are at risk for laceration at any time, but laceration occurs most frequently during ROM. The sudden appearance of bright red blood at the time of ROM and a sudden change in the fetal heart rate without other known risk factors should immediately alert the nurse to the possibility of vasa previa.

The presence of placenta previa most likely would be ascertained before labor and is considered a risk factor for this pregnancy. Additionally, if the woman had a placenta previa, it is unlikely that she would be allowed to pursue labor and a vaginal birth.

With the presence of severe abruptio placentae, the uterine tonicity typically is tetanus (i.e., a boardlike uterus).

DIC is a pathologic form of diffuse clotting that consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. DIC is always a secondary diagnosis, often associated with obstetric risk factors such as HELLP syndrome. This woman did not have any prior risk factors.

DIF: Cognitive Level: Analysis REF: 685

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Diagnosis

6. A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination, the nurse notices an ecchymotic blueness around the womans umbilicus. The nurse recognizes this assessment finding as:

a.

Normal integumentary changes associated with pregnancy

b.

Turner sign associated with appendicitis

c.

Cullen sign associated with a ruptured ectopic pregnancy

d.

Chadwick sign associated with early pregnancy

ANS: C

Cullen sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal 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 a blue-purple cervix that may be seen during or around the eighth week of pregnancy.

DIF: Cognitive Level: Analysis REF: 677

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

7. With regard to miscarriage, nurses should be aware that:

a.

It is a natural pregnancy loss before labor begins

b.

It occurs in less than 5% of all clinically recognized pregnancies

c.

It often can be attributed to careless maternal behavior, 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

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 labor, is likely.

Miscarriage is a natural pregnancy loss, but it occurs, by definition, before 20 weeks of gestation, before the fetus is viable.

Miscarriages occur in approximately 15% of all clinically recognized pregnancies.

Miscarriage can be caused by a number of disorders or illnesses outside the mothers control or knowledge.

DIF: Cognitive Level: Comprehension REF: 670

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

8. Bleeding disorders in late pregnancy include all of these except:

a.

Placenta previa

b.

Abruptio placentae

c.

Spontaneous abortion

d.

Cord insertion

ANS: C

Spontaneous abortion is another name for miscarriage; it occurs, by definition, early in pregnancy.

Placenta previa is a well-known reason for bleeding late in pregnancy.

The premature separation of the placenta (abruptio placentae) is a bleeding disorder that can occur late in pregnancy.

Cord insertion may cause a bleeding disorder in later pregnancy.

DIF: Cognitive Level: Knowledge REF: 680

OBJ: Client Needs: Physiologic Integrity, Physiologic Adaptation

TOP: Nursing Process: Assessment

9. With regard to hemorrhagic complications that may present during pregnancy, nurses should know that:

a.

An incompetent cervix usually is not diagnosed until the woman has lost one or two pregnancies

b.

The incidence of ectopic pregnancy is declining as a result of improved diagnostic techniques

c.

One ectopic pregnancy does not affect a womans fertility or her likelihood of having a normal pregnancy the next time

d.

Gestational trophoblastic neoplasia (GTN) is one of the persistently incurable gynecologic malignancies

ANS: A

Short labors and recurring loss of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence.

Because diagnostic technology is improving, more ectopic pregnancies are being diagnosed.

One ectopic pregnancy puts the woman at increased risk for another one. Ectopic pregnancy is a leading cause of infertility.

Once invariably fatal, GTN now is the most curable gynecologic malignancy.

DIF: Cognitive Level: Comprehension REF: 675

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

10. The management of the pregnant client who has experienced a pregnancy loss depends on the type of miscarriage and her signs and symptoms. While planning care for a client who desires outpatient management after a first-trimester loss, the nurse expects the plan of care to include:

a.

Dilation and curettage (D&C)

b.

Dilation and evacuation (D&E)

c.

Misoprostol

d.

Ergot products

ANS: C

Outpatient management of a first-trimester loss is safely accomplished by the use of misoprostol intravaginally for up to 2 days. If there is uncontrollable bleeding, unstable vital signs, or signs of infection a surgical evacuation should be performed.

D&C is a surgical procedure that requires dilation of the cervix and scraping of the uterine walls to remove the contents of pregnancy. This procedure is commonly performed to treat inevitable or incomplete abortion and should be done in the hospital.

D&E is usually performed after 16 weeks of pregnancy. The cervix is widely dilated followed by removal of the contents of the uterus.

Ergot products such as Methergine or Hemabate may be given for excessive bleeding after miscarriage.

DIF: Cognitive Level: Application REF: 672

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

11. Which laboratory marker is indicative of disseminated intravascular coagulation (DIC)?

a.

Bleeding time of 10 minutes

b.

Presence of fibrin split products

c.

Thrombocytopenia

d.

Hyperfibrinogenemia

ANS: B

Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the bodys vasculature.

Bleeding time in DIC is normal.

Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies.

Hypofibrinogenemia occurs with DIC.

DIF: Cognitive Level: Knowledge REF: 686

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

12. A prophylactic cerclage for an incompetent cervix is usually placed at:

a.

11 to 15 weeks of gestation

b.

6 to 8 weeks of gestation

c.

23 to 24 weeks of gestation

d.

After 24 weeks of gestation

ANS: A

A prophylactic cerclage is usually placed at 11 to 15 weeks of gestation. The cerclage is electively removed when the woman reaches 37 weeks of gestation or when her labor begins.

Six to 8 weeks of gestation is much too early to place the cerclage.

Cerclage placement is offered if the cervical length falls to less than 20 to 25 mm before 23 to 24 weeks.

Although no consensus has been reached, 24 weeks is used as the upper gestational age limit for cerclage placement.

DIF: Cognitive Level: Application REF: 675

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

13. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Possible causes of early miscarriage include all except:

a.

Chromosomal abnormalities

b.

Infections

c.

Endocrine imbalance

d.

Systemic disorders

ANS: B

Infections are not a common cause of early miscarriage.

At least 50% of pregnancy losses result from chromosomal abnormalities.

Endocrine imbalances such as hypothyroidism or diabetes are possible causes for early pregnancy loss.

Other systemic disorders that may contribute to pregnancy loss include lupus and genetic conditions.

DIF: Cognitive Level: Knowledge REF: 671

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

MULTIPLE RESPONSE

1. A client who has undergone a dilation and curettage (D&C) for early pregnancy loss is likely to be discharged the same day. The nurse must ensure that vital signs are stable, that bleeding has been controlled, and that the woman has adequately recovered from the administration of anesthesia. In order to promote an optimal recovery, discharge teaching should include:

a.

Iron supplementation

b.

Resumption of intercourse at 6 weeks postprocedure

c.

Referral to a support group if necessary

d.

Expectation of heavy bleeding for at least 2 weeks

e.

Emphasizing the need for rest

ANS: A, C, E

The woman should be advised to consume a diet high in iron and protein. For many women, iron supplementation also is necessary. Acknowledge that the client has experienced a loss, albeit early. She can be taught to expect mood swings and possibly depression. Referral to a support group, clergy, or professional counseling may be necessary. Discharge teaching should emphasize the need for rest.

Nothing should be placed in the vagina for 2 weeks postprocedure. This includes tampons and vaginal intercourse. The purpose of this recommendation is to prevent infection. Should infection occur, antibiotics may be prescribed. The client should expect a scant, dark discharge for 1 to 2 weeks. Should heavy, profuse, or bright bleeding occur she should be instructed to contact her health care provider.

DIF: Cognitive Level: Application REF: 675

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

COMPLETION

1. The condition in which the placenta is implanted in the lower uterine segment near or over the internal cervical os is _________________________.

ANS:

Placenta previa

In placenta previa the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces.

DIF: Cognitive Level: Comprehension REF: 680

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

2. _________________________ is responsible for 9% of all pregnancy-related deaths and is the leading cause of infertility.

ANS:

Ectopic pregnancy

An ectopic pregnancy is one in which the fertilized ovum is implanted outside the uterine cavity. Two percent of all first-trimester pregnancies in the United States are ectopic, and women are less likely to have a successful subsequent pregnancy after an ectopic pregnancy.

DIF: Cognitive Level: Comprehension REF: 676

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

TRUE/FALSE

1. After a fetal loss including miscarriage, the woman should be offered the option of seeing the products of conception. Is this statement true or false?

ANS: T

The woman may also want to know what the hospital does with the products of conception or whether she needs to make a decision about final disposition of the fetal remains.

DIF: Cognitive Level: Application REF: 674

OBJ: Client Needs: Psychologic Integrity

TOP: Nursing Process: Implementation

Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

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