Chapter 31: Obstetric Critical Care My Nursing Test Banks

Lowdermilk: Maternity & Womens Health Care, 10th Edition

Chapter 31: Obstetric Critical Care

Test Bank

MULTIPLE CHOICE

1. A nurse caring for a pregnant woman at 32 weeks of gestation with the diagnosis of severe preeclampsia with pulmonary edema is assisting with the insertion of a pulmonary artery catheter (PAC). As the catheter enters the right ventricle, the main priority of nursing assessment is to:

a.

Assess fetal response to the procedure

b.

Monitor for premature ventricular contractions

c.

Monitor maternal vital signs, especially blood pressure changes

d.

Observe for a complaint of sudden chest pain

ANS: B

The initial nursing action after insertion of a pulmonary artery catheter is to monitor electrocardiogram activity to detect any ventricular ectopy.

Although fetal well-being is important, the primary nursing assessment at this time is to assess the mother for immediate cardiac changes.

It is no longer necessary for the nurse to obtain manual blood pressures because the purpose of the PAC is to monitor internal cardiac pressures.

Any adverse cardiac effects after PAC insertion are first detected through observation of monitoring, before the clients sensory perceptions of cardiac decompensation.

DIF: Cognitive Level: Application REF: 743

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

2. A pregnant woman at 38 weeks of gestation has severe preeclampsia with refractory oliguria. A pulmonary artery catheter is inserted, and the following hemodynamic profile is obtained: CVP, 2 mm Hg; PAP, 17/4 mm Hg; PCWP, 4 mm Hg; CO, 5.1 L/min. One hour after treatment the hemodynamic profile changes to the following: CVP, 2 mm Hg; PAP, 25/7 mm Hg; PCWP, 7 mm Hg; CO, 6.4 L/min. The nurse evaluates the womans condition as:

a.

Improving; the hemodynamic profile is normal

b.

Improving; the cardiac output is greater but with hypervolemia

c.

No better; right preload has not changed

d.

Worsening; pulmonary edema is rapidly developing

ANS: A

These hemodynamic values are all normal.

The PCWP reflects volume changes; this is in the normal range.

The CVP (which reflects preload) is unchanged but was normal in both scenarios. Furthermore, all other hemodynamic values have improved.

There is no indication of pulmonary edema. All values are within normal limits.

DIF: Cognitive Level: Comprehension REF: 747

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Evaluation

3. A nurse caring for a critically ill pregnant woman at 36 weeks of gestation with a pulmonary artery catheter in place obtains the following hemodynamic profile: CVP, 3 mm Hg; PAP, 40/18 mm Hg; PCWP, 18 mm Hg; CO, 7 L/min. The nurse interprets the hemodynamic profile as correlating with:

a.

High left preload

b.

High right preload

c.

Low left preload

d.

Normal right preload

ANS: A

These values indicate a high left preload, which leads to pulmonary edema.

A high CVP reading indicates a high right preload.

The PAP and PCWP are elevated, indicating a high left preload.

The CVP is normal, indicating a normal right preload; however, in this scenario the PAP and PCWP are elevated, indicating an elevated left preload.

DIF: Cognitive Level: Comprehension REF: 749

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment, Diagnosis

4. A nurse caring for a critically ill pregnant woman at 36 weeks of gestation with a pulmonary artery catheter in place obtains the following hemodynamic profile: CVP, 3 mm Hg; PAP, 40/18 mm Hg; PCWP, 18 mm Hg; CO, 7 L/min. The nurse administers a diuretic drug as ordered for the client. From evaluation of the hemodynamic profile, the nurse recognizes that this drug was given to treat:

a.

Cardiogenic pulmonary edema

b.

Hypovolemia

c.

Noncardiogenic pulmonary edema

d.

Preeclampsia

ANS: A

The elevated PAP and PCWP indicate cardiogenic pulmonary edema.

Hypovolemia is indicated by a low, not a high, PAP and PCWP.

Hemodynamic values tend to be normal with noncardiogenic pulmonary edema.

Pulmonary edema may be secondary to preeclampsia caused by the diuretic given to treat the pulmonary edema. An antihypertensive and smooth muscle relaxant (magnesium sulfate) is given to treat preeclampsia.

DIF: Cognitive Level: Analysis REF: 749

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation, Evaluation

5. A nurse assessing for internal hemorrhage after blunt abdominal trauma in a pregnant woman at 28 weeks of gestation most closely observes for:

a.

Alteration in maternal vital signs, especially blood pressure

b.

Complaints of abdominal pain

c.

Changes in fetal heart rate (FHR) patterns

d.

Vaginal bleeding

ANS: C

EFM tracings can help evaluate maternal status after trauma. EFM tracings reflect fetal cardiac responses to hypoxia and hypoperfusion. Careful monitoring of fetal status assists greatly in maternal assessment, because the fetal monitor tracing works as an oximeter of internal maternal well-being.

Hypoperfusion may be present in the pregnant woman before the onset of clinical signs of shock. Electronic fetal monitoring (EFM) tracings show the first signs of maternal compromise, such as when the maternal heart rate, blood pressure, and color appear normal, yet the EFM printout shows signs of fetal hypoxia.

Abdominal pain in and of itself is not the most important symptom. If it is accompanied by contractions, changes in FHR, rupture of membranes, or vaginal bleeding the client should be evaluated for abruptio placentae.

Clinical signs of hemorrhage do not appear until after a 30% loss of circulating volume occurs. Vaginal bleeding may be a sign of abruptio placentae if accompanied by uterine tenderness or pain, contraction, leaking of amniotic fluid, or a change in FHR characteristics.

DIF: Cognitive Level: Comprehension REF: 751

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

6. A pregnant woman at 33 weeks of gestation is brought to the birthing unit after a minor automobile accident. She has no pain and no vaginal bleeding, her vital signs are stable, and the fetal heart rate (FHR) is 132 with variability. The nurse should:

a.

Monitor the woman for a ruptured spleen

b.

Obtain a physicians order to discharge her home

c.

Monitor her for 24 hours

d.

Use continuous electronic fetal monitoring (EFM) for a minimum of 4 hours

ANS: D

External FHR and contraction monitoring are recommended after blunt trauma in a viable gestation for a minimum of 4 hours, regardless of injury severity. Fetal monitoring should be initiated as soon as the woman is stable.

No clinical findings indicate the possibility of a ruptured spleen.

EFM should continue for a minimum of 4 hours after a minor trauma if maternal and fetal findings are normal. Once this has been completed and the health care provider is reassured of fetal well-being, the client may be discharged home.

The client should be monitored for 4 hours after a minor auto accident; 24 hours is unnecessary unless the strip is abnormal or nonreassuring.

DIF: Cognitive Level: Application REF: 754

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

7. A pregnant woman at term is transported to the emergency department (ED) after a severe vehicular accident. The obstetric nurse responds and rushes to the ED with a fetal monitor. Cardiopulmonary arrest occurs as the obstetric nurse arrives. The first thing for the ED and obstetric team to do is to:

a.

Obtain IV access and start aggressive fluid resuscitation

b.

Quickly apply the fetal monitor to determine whether the fetus is alive

c.

Start cardiopulmonary resuscitation (CPR)

d.

Transfer the woman to the operating room for an emergency cesarean delivery in case the fetus is still alive

ANS: C

In a situation of severe maternal trauma, the systematic evaluation begins with a primary survey and the initial ABCs of resuscitation. CPR is initiated.

CPR is initiated first followed by IV replacement fluid.

After immediate resuscitation and successful stabilization measures, a more detailed secondary survey of the mother and fetus should be accomplished.

Attempts at maternal resuscitation are made, followed by a secondary survey of the fetus. In the presence of multisystem trauma, a cesarean delivery may be indicated to increase the chance for maternal survival.

DIF: Cognitive Level: Application REF: 751

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

8. It is extremely rare for a woman to die in childbirth; however, it does happen. In the United States the yearly occurrence is 12 maternal deaths per 100,000 cases of live birth. Leading causes of maternal death are:

a.

Embolism and preeclampsia

b.

Trauma and motor vehicle accidents

c.

Hemorrhage and infection

d.

Underlying chronic conditions

ANS: B

Trauma is the leading cause of obstetric maternal mortality. Motor vehicle accidents account for more than 50% of trauma incidents.

Although preeclampsia and embolism are significant contributors to perinatal morbidity, these are not the leading cause of maternal mortality.

Maternal death caused by trauma may occur as the result of hemorrhagic shock or abruptio placentae. In these cases the hemorrhage is the result of trauma, not childbirth.

The wish to become a parent is not eliminated by a chronic health problem, and many women each year risk their lives to have a baby. Because of advanced pediatric care many women are surviving childhood illness and reaching adulthood with chronic health problems such as cystic fibrosis, diabetes, and pulmonary disorders.

DIF: Cognitive Level: Comprehension REF: 755

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

9. Obstetric nurses have been comfortable providing family-centered maternity care for many years. Many intensive care units (ICUs) are adopting a family-centered care philosophy; however, being far from the obstetric unit makes it much more difficult should a maternity client be transferred to this setting. What action would the nurse encourage to promote family-centered maternity care?

a.

Visiting hours should be during times when nursing care is not being provided.

b.

Siblings should not be encouraged to visit the ICU setting.

c.

Family visitation should be determined based on the clients condition.

d.

Parent-infant interaction and attachment should be facilitated.

ANS: D

The neonate should be brought to the mothers bedside as her condition permits. If the infant is too sick to leave the neonatal intensive care unit, photos should be brought to the mother and placed within her range of vision. Never assume that the mother is too ill to want to see or hold her infant. Encourage this interaction and observe the mothers body language for fatigue.

Although a great deal of nursing care is required in an ICU setting, open visitation so that spouse or other family members are present is essential when providing family-centered care. These family members can provide support and are often included in assisting with the clients care. Nursing care activities should be consolidated as much as possible.

Sibling visitation is very reassuring for the critically ill mother. This allows the sibling to be included in some portion of the birth experience. Nursing staff can explain the equipment depending on the age of the child. The child will be comforted by seeing his or her mother regardless of the scariness of an ICU setting.

Visitation should be based on the mothers desires. The nurse should not assume that she does not want her family to visit because of her condition. In fact, the critically ill mother needs the support and care of her family perhaps even more than the healthy mother.

DIF: Cognitive Level: Application REF: 754, 755

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

MULTIPLE RESPONSE

1. Conditions that classify the parturient as critically ill and indicate the need for a pulmonary catheter include:

a.

Acute respiratory distress syndrome (ARDS)

b.

Shock of undefined source

c.

Severe preeclampsia

d.

Sepsis

e.

Massive blood loss

ANS: A, B, C, D, E

ARDS, shock, severe preeclampsia, sepsis, and massive blood loss are indicative of the need for a pulmonary catheter insertion in the pregnant client, especially if oliguria, hypotension, pulmonary edema, or underlying disease are present.

DIF: Cognitive Level: Application REF: 737

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

COMPLETION

1. Removal of the stressor of pregnancy early in the process of resuscitation may increase the chance for maternal survival. Therefore, in the presence of multisystem trauma, _________________________ may be indicated.

ANS:

Perimortem cesarean

It should also be noted that fetal survival is unlikely if cesarean birth is accomplished more than 20 minutes after maternal death. Therefore, to facilitate resuscitative efforts, a cesarean birth should be performed after 4 minutes of resuscitation if there is no evidence of maternal pulse.

DIF: Cognitive Level: Comprehension REF: 754

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

2. Pregnancy is a ______________________ state, as preparation is made for the blood loss that accompanies childbirth.

ANS:

Hypercoagulable

Coagulation factors and fibrinogen are all increased in pregnancy. Bleeding and clotting times remain unchanged even when hypovolemia and hemodilution are present.

DIF: Cognitive Level: Comprehension REF: 738

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

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

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