Mod 9 ATI test- Hemorrhagic Disorders Assessment

A client arrives in labor and deliver L&D who is gravida 2 para 1.

Client is at 36 weeks of gestation with no past medical problems. Has been experiencing hypertension during pregnancy. No history of drug or alcohol abuse.

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Click to highlight the findings that require immediate follow-up.

When analyzing cues, a thorough nursing assessment is important. Monitoring the vital signs of the client allows the nurse to assess for hypovolemia. Intake and output, including blood loss, should also be measured closely. The nurse should also assess the fetal heart tracing and heart rate to determine if the fetus is experiencing a non-reassuring fetal heart tracing. The client with a suspected placental abruption should be assessed for unexpected uterine contractions that are low frequency and occur too often. The nurse caring for this client should also monitor for pain. Excessive vaginal bleeding can be a sign of placental abruption and requires immediate follow-up. A category 3 fetal heart tracing is an indicator of fetal distress and requires immediate follow-up. Blood pressure 88/64 mm Hg, a heart rate of 115/min, and respiratory rate of 26/min, in addition to the other findings, suggest a large bleed and hypovolemia due to a possible placental abruption and requires immediate attention.

The nurse is caring for a client who had a spontaneous abortion.

Admission Assessment

0900:Client is crying uncontrollably. They have been trying to get pregnant for 10 years and finally IVF worked. They have had 2 miscarriages. Last menstrual period was 9 weeks ago. Awake alert, oriented x 3. Speech clear. Pupils equal and reactive to light. Lung sounds clear, heart sounds regular, bowel sounds normoactive in all quadrants. Pedal pulses palpable bilaterally. Grips equal. Minimal lochia rubra noted.

Which of the client's manifestations should the nurse understand requires prompt attention by the nurse? Select all that apply.

- Reports of being light-headed and dizzy

- Abdominal pain

- Temperature

- Vaginal bleeding

When recognizing cues, the nurse should understand most clients who are experiencing a pregnancy loss have few serious complications. Hemorrhage and infection are the most serious complications; they require prompt attention and can lead to adverse outcomes if not treated. Past spontaneous abortions can increase the risk of another loss, but it does not imply that the client cannot have a viable pregnancy. Vaginal bleeding may or may not occur during a spontaneous abortion, but when it does, there may be passage of tissue as well. Abdominal or uterine cramping is also possible, but should not be severe and is not always present. Occasionally, infection can occur. Septic abortion could cause the client to experience fever, purulent, foul-smelling vaginal discharge, and tachycardia. These require immediate follow-up.

A nurse is caring for a client who has placenta previa. Place the following actions in the correct order of nursing action.

- Assess the client for obstetrical history and signs of bleeding.

- Assess the fetal heart rate

- Measure the blood loss to get an accurate amount

- Obtain IV access

- Prepare the client for delivery if indicated

The nurse should first assess the client, followed by assessing the fetus. Then the nurse should measure the client's blood loss, followed by inserting an IV. Finally, the nurse should prepare the client for surgery.

A nurse is caring for several clients who have been diagnosed with placental abruption. Which of the following clients may require an urgent cesarean delivery?

A client with a category III fetal heart tracing whose vaginal delivery is not imminent.

A category III fetal heart tracing is a non-reassuring pattern that requires an urgent cesarean birth.

A nurse is providing medication teaching to a client who has a new prescription for a low molecular weight heparin (LMWH). Which of the following statements should the nurse include in the teaching? (Select all that apply.)

"An electric razor is recommended for shaving" is correct. An electric razor decreases the risk of bleeding following shaving.

"Any head injury should be evaluated by the emergency department" is correct. Any head injury the client has should be examined by a provider.

"Seek care for cuts that won't stop bleeding" is correct. Excessive bleeding needs to be monitored.

"Use caution when clipping toenails" is correct. Accidental injury when clipping toenails can cause excessive bleeding.

A nurse is caring for a client who is experiencing a spontaneous abortion. Which of the following statements by the client requires the nurse to intervene?

"I should wait 6 months before trying to get pregnant again"

There is no evidence that a client should wait to get pregnant.

A nurse is teaching a client who has been prescribed methotrexate to treat an ectopic pregnancy. Which of the following should the nurse include in the teaching?

Avoid consuming alcohol

Alcohol should be avoided when taking methotrexate.

A nurse is caring for a client who is experiencing a placental abruption. The client has slight uterine tenderness and no vaginal bleeding. The client's vital signs are: blood pressure 118/72 mm HG, heart rate 78/min, respiratory rate 18/min, and temperature 37°C (98.6°F) and the nurse notes a reassuring fetal heart pattern. Which of the following classification of placental abruption should the nurse identify with this client?

Class 1

A client with a class 1 placental abruption would present with zero to small amount of vaginal bleeding, slight uterine tenderness, stable vital signs, no manifestation of fetal distress.

A nurse is teaching a client who has a history of placental abruption preparation for future pregnancy. Which of the following should the nurse include in the teaching? (SATA)

"The submucosal myomas that you have should be removed prior to another pregnancy" is correct. Submucosal myomas may also be associated with placental abruption and should be removed prior to pregnancy.

"Smoking cessation is recommended prior to pregnancy" is correct. The client should quit smoking before getting pregnant again.

"There is an increased risk for an abruption in future pregnancies" is correct. The client does have an increased risk for recurrent placental abruption in the future.

"You should see your provider for blood pressure management prior to getting pregnant again" is correct. Blood pressure should be under control before becoming pregnant again.

A nurse is caring for a client in the clinic who believes they are experiencing a spontaneous abortion. Which of the following manifestations should the nurse anticipate in a spontaneous abortion? (SATA)

Uterine cramping is correct. Uterine cramping may be a sign of spontaneous abortion.

Vaginal bleeding is correct. Vaginal bleeding may be a sign of spontaneous abortion.

Foul smelling vaginal discharge is correct. Foul smelling vaginal discharge may be a sign of spontaneous abortion.

A nurse is caring for a client who has a possible clotting disorder. Which of the following findings are associated with the client's diagnosis? (SATA)

Lasting menstrual periods that last for longer than 7 days and up 10 days is correct. A client with a clotting disorder could have heavy bleeding during menstruation, which may include bleeding that lasts longer than 7 days and up to 10 days.

Develops bruises easily is correct. A client with a clotting disorder could have symptoms of easy or frequent bleeding that can include nosebleeds, easy bruising, excessive bleeding after a medical procedure or dental extraction, and a history of muscle or joint bleeding with no physical injury.

Family history of hemophilia is correct. A client with a clotting disorder could have one or more of the bleeding symptoms and a family member with a bleeding disorder.

Heavy menstrual periods with frequent "golf ball size clots" is correct. A client with a clotting disorder could have gushing of blood, passing clots that are bigger than a grape, and soaking a tampon or pad every hour or more often on the heaviest days.

A nurse is caring for a client with a possible placenta previa who has vaginal bleeding. Which of the following actions should the nurse understand are needed? (SATA)

IV access is correct. IV access may be needed if there is substantial bleeding, or the client is hemodynamically unstable.

Fetal assessment is correct. Fetal assessment should be completed to determine the status of the fetus.

An ultrasound is correct. An ultrasound is needed to determine if there is a placenta previa.

A nurse is teaching a newly licensed about manifestations of an ectopic pregnancy. Which of the following conditions should the nurse teach the newly licensed nurse is frequently mistaken for an ectopic pregnancy? (SATA)

Appendicitis is correct. Manifestations of an ectopic pregnancy, such as abdominal pain, can appear like manifestations of appendicitis.

Early pregnancy loss is correct. Manifestations of an ectopic pregnancy can mimic manifestations of early pregnancy loss, such as vaginal bleeding and abdominal pain.

Ovarian torsion is correct. Manifestations of an ectopic pregnancy, such as abdominal and pelvic pain, can appear like manifestations of ovarian torsion.

Intrauterine pregnancy is correct. Manifestations of an ectopic pregnancy can appear like manifestations of intrauterine pregnancy, such as nausea and vomiting, and a missed period.

A nurse is assessing a group of clients who are pregnant. Which of the following clients should the nurse identify as being at a high risk for cervical insufficiency?

Client with a physical exam showing advanced cervical dilation and/or effacement without any signs of labor.

The diagnosis is made when a client has a physical exam showing advanced cervical dilation and/or effacement without any signs of labor and no other diagnosis, such as labor, infection, placental abruption or placental previa.

A nurse is caring for a client who is at 34 weeks of gestation and reports moderate vaginal bleeding, severe abdominal pain, and recent cocaine use. The nurse should understand that which of the following is a risk factor for placental abruption?

The client reports recent cocaine use.

Cocaine use increases the risk of placental abruption.

A nurse is caring for a client with an ectopic pregnancy who reports severe abdominal pain. The client's vital signs are: blood pressure 86/40 mm HG, heart rate 102/min, respiratory rate 20/min, temperature 37° C (98.6° F). The nurse should expect to prepare the client for which of the following treatments?

Surgery

Surgery is the only appropriate treatment for an unstable client.

A nurse is caring for a pregnant client who has a history of cervical insufficiency. The nurse should understand that which of the following are risk factors for cervical insufficiency? (SATA)

Loop electrosurgical excision procedure (LEEP) in correct. A LEEP procedure is a risk factor for cervical insufficiency.

Cervical laceration during previous delivery is correct. Previous cervical laceration is a risk factor for cervical insufficiency.

A nurse is caring for a pregnant client who is anxious because of their medical history of a thrombophilia. The nurse is aware that which of the following variants of thrombophilia can cause recurrent early pregnancy loss?

Antiphospholipid syndrome

Antiphospholipid syndrome can be a cause of recurrent early pregnancy loss.

Antiphospholipid syndrome is an autoimmune disorder where the body's immune system mistakenly produces antibodies that attack phospholipids, which are part of cell membranes and proteins, leading to an increased risk of blood clot

A nurse is caring for a client who was recently diagnosed with Factor V Leiden. Which of the following should the nurse understand is the cause of this disorder?

Gene mutation

Gene mutations are the cause of inherited thrombophilia.

Factor V Leiden is a genetic disorder that increases the risk of developing abnormal blood clots, mainly in the veins, which can lead to serious complications like deep vein thrombosis (DVT) and pulmonary embolism (PE). It's caused by a mutation in the gene for factor V, a protein that helps blood clot

A nurse is caring for a client who has placenta previa. Which of the following clients are at risk for placenta previa? (SATA)

A G4P3 with a history of three cesarean births is correct. Previous cesarean births and increasing parity are risk factors for placenta previa.

A G1P0 who uses cocaine regularly is correct. Cocaine use is a risk factor for placenta previa

A G1P0 pregnant through in vitro fertilization is correct. In vitro fertilization is a risk factor for placenta previa.

A nurse is providing teaching to a client who is diagnosed with a pregnancy in which the sperm fertilized an empty egg. Which of the following should the nurse include in the teaching about follow-up?

The client will need three monthly hCG levels after the first normal one.

In a complete molar pregnancy, 3 monthly hCG levels are needed after a normal one.

A nurse is caring for a client who has a chronic placental abruption. Which of the following findings should the client anticipate?

Fetal growth restriction

A chronic abruption can cause fetal growth restriction due to a decrease in oxygen and nutrients being passed to the fetus.

Chronic placental abruption, a slow-developing form of placental abruption, occurs when the placenta partially or completely separates from the uterine wall before delivery, potentially leading to light, intermittent vaginal bleeding and slowed fetal growth.

An acute abruption can cause an urgent delivery, not a chronic placental abruption.

A nurse is caring for a client who is at 12 weeks of gestation and has vaginal bleeding and pain. Which of the following factors increases the client's risk for ectopic pregnancy?

The client that became pregnant with an intrauterine device.

The ectopic rate is as high as 53% for a pregnancy that occurs with an intrauterine device.

A nurse is caring for several pregnant clients. Which of the following client are at a higher risk for spontaneous abortion? (SATA)

A 26-year-old client with a BMI of 16 and a history of anorexia nervosa is correct. Clients who have a BMI of less than 20 kg/m, clients greater than 40 years of age, and clients who smoke are at higher risk for a spontaneous abortion.

A 42-year-old client who is pregnant for the first time is correct. Clients who have a BMI of less than 20 kg/m, clients greater than 40 years of age, and clients who smoke are at higher risk for a spontaneous abortion.

A 16-year-old client who smokes cigarettes is correct. Clients who have a BMI of less than 20 kg/m, clients greater than 40 years of age, and clients who smoke are at higher risk for a spontaneous abortion.

A nurse is teaching a client who has a clotting disorder. Which of the following statements from the client demonstrates understanding of the condition?

"I will stop my low molecular weight heparin when I go into labor."

The client should stop taking the low molecular weight heparin when they go into labor to prevent excessive bleeding.

A nurse is caring for a client who has cervical insufficiency. Which of the following are possible causes of cervical insufficiency? (SATA)

The client had prior cold knife conization is correct. Prior cold knife conization, prior vacuum delivery, and prior exposure to diethylstilbestrol in utero are possible causes of cervical insufficiency.

The client had a vacuum delivery with a previous child is correct. Prior cold knife conization, prior vacuum delivery, and prior exposure to diethylstilbestrol in utero are possible causes of cervical insufficiency.

The client was exposed to diethylstilbestrol in utero is correct. Prior cold knife conization, prior vacuum delivery, and prior exposure to diethylstilbestrol in utero are possible causes of cervical insufficiency.

Diethylstilbestrol is a synthetic non-steroidal estrogen that was historically widely used to prevent potential miscarriages by stimulating the synthesis of estrogen and progesterone in the placenta (in the United States of America, especially from the 1940s to the 1970s)

Cold knife conization, also known as a cold knife cone biopsy, is a surgical procedure to remove a cone-shaped piece of tissue from the cervix using a scalpel or laser knife. It's typically used to diagnose and treat precancerous conditions or early-stage cervical cancer.

A nurse is caring for a client with a known thrombophilia who is receiving low molecular weight heparin. The nurse should understand that this client is at high risk for which of the following?

Postpartum hemorrhage

A client receiving anticoagulants is at high risk for postpartum hemorrhage.

A nurse is caring for a client who was admitted with an ectopic pregnancy.

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

When generating solutions, the nurse should recognize that expectant management is management that monitors the client while waiting for the ectopic pregnancy to resolve. This is only appropriate for asymptomatic clients with an ectopic pregnancy of unknown location that is not in a fallopian tube and who have a hCG serum level that is low (at least 200 mIU/mL) and declining. These clients can remain at home with appropriate office follow up.

Medication management at home with methotrexate is appropriate for hemodynamically stable clients with a confirmed ectopic pregnancy without rupture.

Surgery is required for unstable clients, clients with suspected tubal rupture, a heterotopic pregnancy with a coexisting viable intrauterine pregnancy, or a contraindication to methotrexate use or failed methotrexate treatment.

These clients should also avoid vigorous activity and sexual activity until the ectopic pregnancy has resolved to avoid rupture.