Which finding would lead the nurse to suspect that the fetus of a woman in labor?

Q: Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic?

A hypertonic pattern typically has elevated resting pressures, increased contraction frequency, and decreased coordination, as well as a delayed fall to baseline uterine tone. This pattern is seen more often with fetal malpresentation and uterine overdistention.

Q: What is the fetal response to labor?

The fetal head has the ability to change shape to fit through the pelvis. This ability of the head to change shape is called molding. Because of the tilt of the pelvis, the fetus descends through this pathway during labor and birth, as shown in Figure 2.4.

Q: When describing the stages of labor to a pregnant woman which would the nurse identify as the major change occurring during the first stage?

The first stage of labor begins with the onset of regular uterine contractions that dilate (open) the cervix. It is completed when the cervix is completely or fully dilated at 10 centimeters (about four inches).

Q: What signs and symptoms would lead the nurse to suspect a uterine rupture is occurring?

What are the symptoms of uterine rupture?.

Tobacco, alcohol and drugs can have harmful effects on anyone's health. When a pregnant or nursing woman uses these substances, her baby also is exposed to them, for all substances cross the placenta through the umbilical cord and enter into the baby's bloodstream.

Inhaltsverzeichnis Show

"Street" Drugs
Prescription Drugs
Over-the-Counter Medicines and Vitamins
Preeclampsia and Eclampsia NCLEX Questions Quiz
Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic?
What is the fetal response to labor?
When describing the stages of labor to a pregnant woman which would the nurse identify as the major change occurring during the first stage?
What signs and symptoms would lead the nurse to suspect a uterine rupture is occurring?

While pregnant, it is best to eat well, stay healthy and avoid ingesting anything that might be harmful to the mother's or baby's health. A health care provider can give you more information about these issues.

"Street" Drugs

A pregnant woman who uses drugs like cocaine, crack, heroin and methadone may have a baby born addicted to the substances she took during her pregnancy. Cocaine is one of the most harmful drugs to unborn babies. Cocaine can cause a woman to miscarry and may cause preterm birth, bleeding, fetal death and fetal strokes, which can lead to brain damage and death. After birth, a baby who has been exposed to cocaine prenatally goes through withdrawal, signs of which include jitters and irritability. These babies are hard to comfort and are often unable to respond to their mothers. Cocaine use during pregnancy also may be linked to an increased risk of sudden infant death syndrome, or SIDS.

Amphetamines or "speed" also are harmful to unborn babies. One study showed that the fetuses of mothers who used speed during pregnancy had decreased weight, length and head size. Another study showed that these babies had more strokes, or bleeding into their brains.

Marijuana

Marijuana can affect fetal and infant development and may cause miscarriage. Although the effects of marijuana on an unborn baby are still unknown, studies have indicated that prenatal marijuana use is linked to premature births, small birth size, difficult or long labor and an increase in newborn jitteriness.

Marijuana smoked by a pregnant woman remains in the baby's fat cells for seven to 30 days. Smoking marijuana can affect the amount of oxygen and nutrients the baby receives, which may affect growth. Marijuana is never safe during pregnancy and it can harm the baby at any stage. In addition, marijuana can have long-term effects on infants and children, such as having trouble paying attention or learning to read.

Alcohol

Drinking alcohol can increase the risk of miscarriage, stillbirth, newborn death and fetal alcohol syndrome (FAS). Babies with FAS have low birth weight, heart defects, facial defects, learning problems and mental retardation. Since it is not known if there is a safe level of alcohol during pregnancy, the best advice is not to drink at all. Even one drink a day has been shown to have effects on the growing fetus. The best time to stop drinking alcohol is before you conceive. If your pregnancy is unplanned, you should stop drinking as soon as you suspect you are pregnant.

Tobacco

Women who smoke during pregnancy are more likely to have babies who are too small. Smoking also increases the risk of miscarriage, preterm labor, stillbirth and newborn death. Babies born weighing less than 5 pounds may have more health problems early in life and learning problems later in school. If you smoke, quit now. Ask your health care provider for information about classes or support groups for pregnant women who want to quit smoking.

Prescription Drugs

Some prescribed medications may be harmful to your unborn or nursing baby. If you are taking any prescribed drugs, tell your health care provider as soon as possible so that your medications can be changed or adjusted as needed.

Over-the-Counter Medicines and Vitamins

Avoid over-the-counter medicines such as antacids, laxatives, sleeping pills, cold medications and pain relievers. While some are safe for pregnant women, many are not. If you feel you need any of these medications, first check with your health care provider. This applies to large doses of over-the-counter vitamin preparations as well, for taking large doses of extra vitamins can be harmful to you and your baby.

Caffeine

Caffeine is present in coffee, tea, cola drinks and some medications. For at least 10 years, there has been controversy over whether caffeine is harmful during pregnancy. Some studies suggest caffeine is harmful, pointing to an increased risk of miscarriage, early delivery or lower birth weight. Other studies have shown that women who consume a moderate amount of caffeine do not experience these problems. Because results are conflicting, no one knows the true risk. We recommend drinking as little caffeine as possible.

Ask your health care provider for more information about substances and their effects on pregnancy. Remember -- your baby needs a healthy mom!

Preeclampsia and eclampsia NCLEX questions for nursing students!

Preeclampsia is a complication that can occur during pregnancy. If severe, it can lead to eclampsia, which is seizure activity that can progress to a coma or death. It is important you know about this condition for maternity nursing exams. For example, be familiar with testing, nursing care, complications, and signs and symptoms.

Before taking the quiz, don’t forget to watch the lecture on preeclampsia and eclampsia.

Preeclampsia and Eclampsia NCLEX Questions Quiz

This quiz will test your nursing knowledge on preeclampsia and eclampsia in preparation for NCLEX.

1. The nurse knows that preeclampsia tends to occur during what time in a pregnancy?*
- A. before 20 weeks
- B. in the third trimester and postpartum
- C. after 20 weeks
- D. in the first and second trimester
2. A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply:*
- A. 1600: blood pressure 144/100, 1700: blood pressure 120/80
- B. 3+ dipstick urine protein
- C. 1 hour glucose tolerance test 90 mg/dL
- D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98
- E. <300 mg/dL 24-hour urine protein
3. You're providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops?*
- A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta."
- B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter."
- C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs."
- D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia."
4. A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient’s education? Select all that apply:*
- A. Report weight gain of >4 lbs in one week to physician
- B. Incorporate foods like eggs, nuts, fish, meat in your diet
- C. Follow a no salt diet
- D. Headache and vision changes are expected side effects of this condition and cause no reason for concern.
- E. Importance of monitoring urine protein at home
- F. Lying on left-side is recommended along with rest
- G. Report a decrease in fetal activity immediately
5. Fill-in-the-blank: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom's body, which injures organs.*
- A. spiral arteries
- B. epithelial cells
- C. endothelial cells
- D. juxtaglomerular cells
6. Select all the risk factors below that increases a woman’s risk for developing preeclampsia:*
- A. Nulligravida
- B. Primigravida
- C. BMI 34
- D. Pregnant with twins
- E. Maternal history of preeclampsia
- F. Age: 25-years-old
- G. History of Lupus and Diabetes
7. Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient’s lab results correlate with HELLP Syndrome?*
- A. Hemoglobin 12 g/dL
- B. Platelets 90,000 μL
- C. ALT 100 IU/L
- D. AST 90 IU/L
- E. Glucose 350 mg/dL
- F. Abnormal RBC peripheral smear
8. Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby?*
- A. Acetylcysteine
- B. Calcium carbonate
- C. Oxytocin
- D. Calcium gluconate
9. A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician?*
- A. Deep tendon reflex 4+
- B. Respiratory rate of 13 breaths per minute
- C. Urinary output of 600 mL over 12 hours
- D. Clonus presenting in the lower extremities
- E. Patient reports flushing or feeling hot
10. In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of experiencing a seizure due to central nervous system irritability? Select all that apply:*
- A. You note bouncing of the foot when it is quickly dorsiflexed.
- B. Patellar and bicep deep tendon reflexes are graded 4+.
- C. Platelet count 200,000
- D. Patient reports a decrease in headache pain.
11. How would the nurse check for clonus in a patient with preeclampsia?*
- A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction.
- B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms.
- C. Assess for beating of the foot when the foot is quickly dorsiflexed.
- D. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.
12. A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure?*
- A. Placing the patient in a supine position
- B. Holding down the patient’s head to prevent injury
- C. Staying with the patient and activating the emergency response team
- D. Timing the seizure
- E. Providing 8 to 10 L of oxygen

(NOTE: When you hit submit, it will refresh this same page. Scroll down to see your results.)

1. The nurse knows that preeclampsia tends to occur during what time in a pregnancy?

A. before 20 weeks

B. in the third trimester and postpartum

C. after 20 weeks

D. in the first and second trimester

The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.

2. A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply:

A. 1600: blood pressure 144/100, 1700: blood pressure 120/80

B. 3+ dipstick urine protein

C. 1 hour glucose tolerance test 90 mg/dL

D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98

E. <300 mg/dL 24-hour urine protein

The answers are B and D. Signs and symptoms of preeclampsia include: proteinuria (>1+ dipstick urine protein or >300 mg/dL 24 hour urine protein, hypertension >140/90…two reading at least 4-6 hours apart), swelling in face, eyes, extremities, headaches, vision changes, etc.

3. You’re providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops?

A. “The basal arteries of the myometrium fail to widen to support blood flow to the placenta.”

B. “The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter.”

C. “The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs.”

D. “If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia.”

The answer is B. This is the only correct statement. When preeclampsia occurs it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom’s circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.

4. A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient’s education? Select all that apply:

A. Report weight gain of >4 lbs in one week to physician

B. Incorporate foods like eggs, nuts, fish, meat in your diet

C. Follow a no salt diet

D. Headache and vision changes are expected side effects of this condition and cause no reason for concern.

E. Importance of monitoring urine protein at home

F. Lying on left-side is recommended along with rest

G. Report a decrease in fetal activity immediately

The answers are: B, E, F, and G. These options are topics the nurse wants to include in the patient’s teaching with preeclampsia. Option A is wrong because the patient should report a weight gain of >2 lbs (NOT 4 lbs) in one week. Option C is wrong become it is no longer recommended the patient restrict salt in diet but limit it. Option D is wrong because a headache and vision changes are serious complications that may indicate the development of eclampsia, and the patient should report it immediately.

5. Fill-in-the-blank: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom’s body, which injures organs.

A. spiral arteries

B. epithelial cells

C. endothelial cells

D. juxtaglomerular cells

The answer is C: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the ENDOTHELIAL CELLS in mom’s body, which injures organs.

6. Select all the risk factors below that increases a woman’s risk for developing preeclampsia:

A. Nulligravida

B. Primigravida

C. BMI 34

D. Pregnant with twins

E. Maternal history of preeclampsia

F. Age: 25-years-old

G. History of Lupus and Diabetes

The answers are: B, C, D, E, and G. Risk factors for preeclampsia include: History of preeclampsia or family history, first pregnancy (primigravida), significant health history prior to pregnancy: diabetes, lupus, high blood pressure, kidney disease, Obese: BMI >30, having more than one baby (twins, triplets etc.), age (young <18 or advanced >35).

7. Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient’s lab results correlate with HELLP Syndrome?

A. Hemoglobin 12 g/dL

B. Platelets 90,000 μL

C. ALT 100 IU/L

D. AST 90 IU/L

E. Glucose 350 mg/dL

F. Abnormal RBC peripheral smear

The answers are: B, C, D, and F. HELLP Syndrome causes of Hemolysis of RBCs (abnormal RBC peripheral smear), Elevated Liver enzymes (>70 IU/L for AST or ALT), Low Platelets (<100,000 μL ).

8. Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby?

A. Acetylcysteine

B. Calcium carbonate

C. Oxytocin

D. Calcium gluconate

The answer is D: The antidote for Magnesium Sulfate is Calcium Gluconate. The nurse should have this on hand in case Magnesium toxicity occurs.

9. A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician?

A. Deep tendon reflex 4+

B. Respiratory rate of 13 breaths per minute

C. Urinary output of 600 mL over 12 hours

D. Clonus presenting in the lower extremities

E. Patient reports flushing or feeling hot

The answer is E. The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

10. In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of experiencing a seizure due to central nervous system irritability? Select all that apply:

A. You note bouncing of the foot when it is quickly dorsiflexed.

B. Patellar and bicep deep tendon reflexes are graded 4+.

C. Platelet count 200,000

D. Patient reports a decrease in headache pain.

The answers are A and B. Option A indicates positive clonus and Option B is indicative of hyperreflexia. If these findings are present it demonstrates that the central nervous system is irritated and there is a high risk of potential seizure activity. Seizure precautions should be initiated and the physician notified.

11. How would the nurse check for clonus in a patient with preeclampsia?

A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction.

B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms.

C. Assess for beating of the foot when the foot is quickly dorsiflexed.

D. Assess for dorsiflexion of the foot by quickly plantar flexing the foot.

The answer is C: To check for clonus the nurse will have the patient dangle the leg and support the patient’s lower leg. Then the nurse will quickly dorsiflex the foot. The nurse is assessing for bouncing or beating of the foot (hence the foot attempts to plantarflex). If the foot attempts to bounce or beat 3 or more times, it is positive for clonus.

12. A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure?

A. Placing the patient in a supine position

B. Holding down the patient’s head to prevent injury

C. Staying with the patient and activating the emergency response team

D. Timing the seizure

E. Providing 8 to 10 L of oxygen

The answers are A and B. The nurse would want to place the patient on their side (preferably the left-side…not supine) to help prevent the tongue from obstructing the airway, preventing aspiration, and improving blood flow to the placenta. In addition, the nurse would NOT want to restrain the patient, which can cause injury. Option C, D, and E are steps the nurse would want to take.

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