Ectopic Pregnancy HESI Case Study

Ectopic Pregnancy - HESI Meet the Client: Darlene Hall Darlene Hall is a married 25-year-old female who works as an attorney. She has been married to her husband James for 2 years. Darlene has no significant medical history and no obstetric history. Her surgical history includes tubes in her ears at 3 years old. She is a social drinker but does not smoke tobacco or use illicit drugs. Her father has hypertension, and her mother had gallbladder disease in her 40s, but the rest of her family has a benign medical history. Instructions: While taking this case study, all questions must be answered correctly before you will be able to proceed to the next page. For all incorrect answers, select a new response and click the Next button. When all questions have been answered correctly, clicking the Next button will display the next page. Page 1 1. Initial History and Assessment Darlene presents to the Emergency Department (ED) at 0615. She reports that she was awakened in the middle of the night with serious pain in her lower right abdomen accompanied by nausea and an episode of vomiting. Admission assessment by the registered nurse (RN) reveals the following: T 98.4° F (36.8° C), P 80, R 20, BP 126/68, pain 9/10 on the pain scale, and her last menstrual period (LMP) was “about a month ago.” Her heart rate is regular, and her lungs are clear to auscultation bilaterally. Palpation of the abdomen elicits complaints of pain in the right lower quadrant of the abdomen. Darlene’s husband James is at her bedside. He suspects that his wife is having an appendicitis attack and is concerned that no ultrasound or blood tests have been done. 2. 1.ID: 6975250373 Which test(s) does the RN anticipate that the healthcare provider (HCP) will order after considering Darlene’s history and symptoms? (Select all that apply.) A. B. Urinalysis (UA) Correct Urinalysis (UA) could reveal a urinary tract infection, a kidney infection, or dehydration. Urine pregnancy test Correct Abdominal pain is a common symptom that can occur in early pregnancy, and a urine pregnancy test is a sensitive indicator of pregnancy. C. Complete Blood Count (CBC) Correct An increased white blood cell (WBC) count can indicate an infection. D. McBurney’s point Correct McBurney’s Point is located midway between the anterior iliac crest and the umbilicus in the right lower quadrant (RLQ). This is the classic area for localized tenderness during late stages of appendicitis. E. Abdominal x-ray An abdominal x-ray is not used to identifying an inflamed appendix, and the uterus is often not seen on an abdominal x-ray. F. Serum human chorionic gonadotropin (hCG) Correct hCG is the hormone that indicates a positive pregnancy. Correct Awarded 1.0 points out of 1.0 possible points. Page 2 1. Based on Darlene’s symptoms, the HCP in the ED orders a UA, urine pregnancy test, CBC, and serum hCG. The results of these tests are as follows: CBC Results Component WBC RBC Hemoglobin Hematocrit MCV MCH MCHC RDW Platelets Test Specific Gravity pH Urine-Color WBC Protein Glucose Ketones Occult Blood Bilirubin Nitrite Normal 3.8-11.0 K/UL 3.50-5.50 MIL/UL 12.0-15.0 G/DL 36.0-48.0% 79.0-101.0 FL 25.0-35.0 PG 31.0-37.0% 11.0-16.0 FL 150-420 K/UL Result 1.024 6.0 Amber Negative Negative Negative Negative Negative Negative Negative Results 4.0 K/UL 4.59 MIL/UL 14.2 G/DL 40.1% 85.3 FL 30.5 PG 33% 12.6 FL 300 K/UL Reference Intervals 1.005-1.030 5.0-7.5 Yellow Negative Negative/Trace Negative Negative Negative Negative Negative Urinalysis Results Darlene's hCG level is 2550 mU/mL and her Urine Pregnancy Test returns a positive result. 2. 2.ID: 6975250326 Based on the provided results, the RN can infer which of the following? A. Darlene has a urinary tract infection and is pregnant. The results of the UA and the CBC are within normal parameters; however, the urine pregnancy test and the serum hCG are positive for a pregnancy. B. Darlene’s lab results indicate a probable appendicitis. Darlene’s lab results indicate a probable appendicitis. C. Darlene does not have a urinary tract infection, but is pregnant. Correct According to the lab results, the UA and CBC are within normal parameters; however, both the urine pregnancy test and the serum hCG are both positive for a pregnancy. D. Darlene has a urinary tract infection. The results of the UA and the CBC are within normal parameters. Correct Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 6975250361 What is the function of hCG? A. hCG is produced during pregnancy. It can help support a pregnancy by allowing for the production of testosterone, the hormone that helps to prepare the lining of the uterus for implantation. Though hCG is produced by the trophoblast during pregnancy, it stimulates the production of progesterone and estrogen to maintain the pregnancy. B. hCG inhibits uterine activity and diminishes the strength of contractions. Relaxin inhibits uterine activity and diminishes the strength of contractions, not hCG. C. hCG serves as an insulin antagonist and reduces the amount of glucose needed by the mother so that more glucose is available for fetal growth. hCG does not inhibit glucose metabolism; the hormone that serves this purpose is human placental lactogen (hPL). D. hCG is produced during pregnancy. It can help support a pregnancy by allowing for the production of progesterone, the hormone that helps to prepare the lining of the uterus for implantation. Correct hCG is produced by the trophoblast during pregnancy, and stimulates the production of progesterone and estrogen to maintain the pregnancy until the placenta is developed. Correct Awarded 1.0 points out of 1.0 possible points. Page 3 1. Safe and Effective Care: Management of Care The HCP in the ED discusses the results of the laboratory tests with Darlene and her husband James and explains that Darlene has a positive pregnancy test. After the HCP leaves the room, Darlene looks at the RN and states, “That can’t be. I have been having my period. How can I be pregnant?” 2. 4.ID: 6975251801 What would be the RN’s appropriate response to the client? A. “It is not uncommon for spotting or light bleeding to occur, especially during the early phases of pregnancy.” Correct Trauma to the cervix, which is highly vascularized during pregnancy, implantation of pregnancy, or lesions in the vagina or cervix can cause bleeding during pregnancy. A woman should report vaginal bleeding during pregnancy to her HCP. B. "Oh, you are correct. There must be a mistake in the lab work. Let’s send them with a fresh specimen.” Bleeding does not invalidate a urine or serum pregnancy test. A repeat urine test could be performed prior to a serum pregnancy test for validation if an error was suspected. C. “Well, you have had nausea too, so you must be pregnant.” Nausea is a presumptive indicator of pregnancy, not a probable indicator of pregnancy. D. “That is true. The hCG must be a result of a pituitary gland problem. The HCP can perform an MRI of your brain.” hCG is not produced because of pituitary gland dysfunction but is produced by the trophoblast. Correct Awarded 1.0 points out of 1.0 possible points. 3. The RN notes that Darlene’s hCG level is 2550 mU/ml and next asks Darlene a series of questions, including when her LMP was, if she smokes, and if she has ever had any sexually transmitted infections (STIs). Darlene reports her last menstrual period was 5 weeks ago and that she had chalymdia 6 years ago. hCG Levels During Pregnancy (in weeks since LMP) 3 weeks 5-50 mlU/mL 4 weeks 5-426 mlU/mL 5 weeks 18-7,340 mlU/mL 6 weeks 1,080-56,500 mlU/mL 7-8 weeks 7,650-229,000 mlU/mL 9-12 weeks 25,700-288,000 mlU/mL 13-16 weeks 13,300-254,000 mlU/mL 17-24 weeks 4,060-165,400 mlU/mL 25-40 weeks 3,640-117,000 mlU/mL non pregnant 55-200 ng/mL 4. 5.ID: 6975250398 Why does the RN ask Darlene these questions? A. B. The HCP wants to rule out hyperemesis gravidarum. The answers to these questions would not rule out hyperemesis gravidarum. The HCP wants to rule out ectopic pregnancy. Correct LMP is used to estimate gestational age. A history of smoking and STIs increases the risk of ectopic pregnancy, as well as other abnormalities. C. The HCP wants to rule out multiple gestation because of high hCG levels. Incorrect A high hCG level does not indicate multiple gestation. Also, Darlene’s hCG level is not considered extremely high. D. The HCP wants to rule out pregnancy because anyone who has had an STI cannot become pregnant. Some STIs can increase the risk of infertility and complications with pregnancy, but women with a history of STIs can become pregnant. Incorrect Awarded 0.0 points out of 1.0 possible points. Page 4 1. 2. Darlene reports that her LMP was 12/08. 6.ID: 6975250387 Using Nägele’s rule, what is Jane’s estimated due date (EDD)? A. 09/15 Correct Nägele’s rule states that to estimate a due date based on the LMP the calculation is as follows: LMP – 3 months + 7 days = EDD. B. 10/14 Nägele’s rule states that to estimate a due date based on the LMP the calculation is as follows: LMP – 3 months + 7 days = EDD. C. 09/11 Nägele’s rule states that to estimate a due date based on the LMP the calculation is as follows: LMP – 3 months + 7 days = EDD. D. 10/20 Nägele’s rule states that to estimate a due date based on the LMP the calculation is as follows: LMP – 3 months + 7 days = EDD. Correct Awarded 1.0 points out of 1.0 possible points. 3. A pelvic exam and transvaginal ultrasound are performed on Darlene, and an adnexal mass and tenderness in the RLQ are noted. Soon after the exam, Darlene complains that the pain is shooting to her right shoulder. Based on the pelvic exam and transvaginal ultrasound findings, a low-risk ectopic pregnancy is diagnosed and no cardiac activity is detected. Page 5 1. 2. Safe and Effective Care: Client Teaching 7.ID: 6975250378 How should the RN explain ectopic pregnancy to Darlene and James? A. “An ectopic pregnancy involves a fertilized ovum in the vagina.” Ectopic pregnancy involves implantation outside of the uterus. B. "An ectopic pregnancy involves a cancerous, fertilized ovum in either fallopian tube.” Ectopic pregnancy does not involve a cancerous growth. C. "An ectopic pregnancy involves a fertilized ovum outside of the uterus that cannot be transferred to the uterus.” Correct Ectopic pregnancy can be located in a variety of positions outside the uterus and is not generally compatible with normal pregnancy and delivery. D. "An ectopic pregnancy does not need major treatment and can be delivered vaginally.” Ectopic pregnancy requires emergency treatment in the majority of cases. Correct Awarded 1.0 points out of 1.0 possible points. 3. Based on the diagnosis of a low-risk ectopic pregnancy with no cardiac activity, the need to discuss treatment options arises. James is very eager to become a father and asks if the ectopic pregnancy has ruined their chance of becoming pregnant again. 4. 8.ID: 6975250381 Which is the best way for the RN to respond? A. "Ectopic pregnancies occur in 12-50% of all pregnancies, depending on the age of the mother. You will have no problem getting pregnant again very soon.” Spontaneous abortion, not ectopic pregnancy, occurs in 12-50% of all pregnancies. Risk for spontaneous abortion (SAB) increases with advancing maternal age. Ectopic pregnancy occurs in about 1% of pregnancies. B. "I am sorry, but you should probably explore adoption options if you are that excited to be a father.” This is not a therapeutic response, and it is inappropriate for the situation. C. "Scar tissue caused by Darlene’s past chlamydia infection will prevent any type of pregnancy from ever occurring.” "Scarring from infections can cause pregnancy complications; however, it does not completely rule out the possibility of pregnancy." D. "You will be screened for the possible administration of a folic acid antagonist called methotrexate that may help maintain the possibility of future pregnancies." Correct Early treatment of ectopic pregnancy involves methotrexate administration. Correct Awarded 1.0 points out of 1.0 possible points. 5. The RN gives Darlene and James some time to process all that they have learned in the short time they have been in the hospital. She asks them if they have any questions. Darlene says, “My sister just had a miscarriage. Does that mean she had chlamydia or any other STI?” 6. 9.ID: 6975250383 How should the RN respond to the Darlene? A. "Yes, she most certainly did. Perhaps she got it the same way you did. I think you better take a closer look at what your husband is doing in his spare time!” It is not appropriate for the RN to make this assumption. B. "No, miscarriages only happen if you drink too much alcohol during the first few weeks of your pregnancy.” Drinking alcohol during pregnancy, particularly in the first trimester, can lead to fetal alcohol syndrome, but it does not necessarily cause miscarriage. C. "No, a miscarriage, which is the lay term for a spontaneous abortion, can happen for a variety of reasons.” Correct A miscarriage is also called a spontaneous abortion. The causes of spontaneous abortion are largely related to chromosomal abnormalities of the embryo or fetus. Other causes can be teratogenic drugs, faulty implantation, weakened cervix, placental abnormalities, and maternal infections. D. "How old is your sister? Perhaps her maternal age caused her to have a miscarriage.” While maternal age does increase the risk of spontaneous abortion, this is not the best response. Correct Awarded 1.0 points out of 1.0 possible points. Page 6 1. Therapeutic Communication: Cultural & Spiritual Consideration When James hears the word abortion, he becomes upset. He states that he was raised to believe that abortion is wrong. The RN spends some time teaching some basic medical terminology to both Darlene and James. 2. 10.ID: 6975250391 What is the correct terminology for a situation in which the non-viable pregnancy is not expelled? A. Elective abortion An elective abortion does not refer to a non-viable pregnancy that is not expelled. B. Spontaneous abortion A spontaneous abortion does not refer to a non-viable pregnancy that is not expelled. C. Missed abortion Correct The term missed abortion refers to a pregnancy in which the fetus has died but the products of conception are retained in utero for up to several weeks. D. Threatened abortion A threatened abortion does not refer to a non-viable pregnancy that has not been expelled. Correct Awarded 1.0 points out of 1.0 possible points. 3. 11.ID: 6975250393 Which term is used to describe the condition when a pregnant woman experiences increased vaginal bleeding and cramping, her internal cervical os dilates, and the membranes may rupture? A. Spontaneous abortion Early vaginal bleeding, dilation, pain and pressure, and probable loss of pregnancy are not associated with a spontaneous abortion. B. Missed abortion Early vaginal bleeding, dilation, pain and pressure, and probable loss of pregnancy are not associated with a missed abortion. C. Septic abortion Early vaginal bleeding, dilation, pain and pressure, and probable loss of pregnancy are not associated with a septic abortion. D. Threatened abortion Correct In a threatened abortion, early vaginal bleeding is the first sign and symptoms progress to dilation, increased pain and pressure, and probable loss of pregnancy. Correct Awarded 1.0 points out of 1.0 possible points. Page 7 1. The HCP discusses Darlene’s status with Darlene and James. After the HCP leaves, James states, “I still don’t like the word ‘abortion.’ Can’t an abortion be called a ‘miscarriage’?” In order to validate James’ feelings, the RN states that the term “miscarriage” is the lay’s term for spontaneous abortion. She then calmly introduces a more in-depth discussion about the different types of spontaneous abortions. 2. 12.ID: 6975251828 Which statement by the couple indicates that they need further teaching? A. “In a threatened abortion, the cervix isn’t dilated and the placenta is attached to the uterine wall.” This statement is true. Bleeding can persist with or without intrauterine fetal demise in threatened abortion. The pregnancy may continue normally or end in spontaneous abortion. Progesterone administration may be considered in hopes of maintaining the pregnancy. B. “In a missed abortion, fetal death occurs but the fetus is not expelled. This condition often requires surgery to prevent complications.”Incorrect This statement is true. Spontaneous expulsion of products of conception (POC) may occur. Surgical intervention, dilation and curettage, may be required to prevent infection. Beyond 12 weeks, induction with IV oxytocin and prostaglandins may be used to expel POC. C. "Habitual abortion refers to three or more consecutive pregnancy losses.” This statement is true. Treatment can vary depending on the history and etiology. D. “Septic abortion can be prevented with good perineal hygiene.” Correct Septic abortion occurs due to presence of infection which could be a result of prolonged, unrecognized rupture of fetal membranes; pregnancy with intrauterine device in utero; or attempts by an inadequately prepared individual to terminate the pregnancy. It is not related to inadequate perineal hygiene. Incorrect Awarded 0.0 points out of 1.0 possible points. Page 8 1. Safe and Effective Care: Therapeutic Communication The RN states that she is very sorry that the couple has to make such a difÏcult decision and reiterates to the couple the HCP’s discussion about interventions that must occur or Darlene’s life will be in danger. Implantation of a fertilized ovum in the fallopian tube puts a client at risk for rupture of the fallopian tube, internal hemorrhage, shock, and death. The couple, after a few private moments, decides to remove the ectopic pregnancy. 2. 13.ID: 6975251820 What is the best response by the RN to the couple regarding their decision to remove the ectopic pregnancy? A. "Excellent Choice. You can always repent later.” The RN’s opinion about the couple’s decision is not warranted in this situation. B. "You will need to sign a consent form stating that you understand the procedure.” Correct A consent form is required for any type of ectopic pregnancy treatment. C. "A visitation to the Pregnancy Loss Counselor for counseling is optional." This is not the priority intervention at this time. D. "Treatment will not cause any major side effects; thus follow-up care will not need to be scheduled.” Additional assessment and monitoring is critical to treatment. Correct Awarded 1.0 points out of 1.0 possible points. 3. 14.ID: 6975251824 Now that the couple has made their decision, what does the RN anticipate the HCP to prescribe initially for treatment? (Select all that apply.) A. Darlene will receive an injection of methotrexate today and possibly a second dose of methotrexate on day 7. Correct This describes the most common treatment for low-risk ectopic pregnancies. B. The HCP will perform a laparoscopic linear salpingostomy to remove the ectopic pregnancy. Incorrect This procedure, which is a surgery that attempts to preserve the fallopian tube, is not warranted for a low-risk ectopic pregnancy but is used for high-risk ectopic pregnancies. C. The RN will administer Rhogam because Darlene is Rh negative. Correct An Rh negative woman should receive a Rhogam injection after any pregnancy, including an ectopic pregnancy. D. The HCP will order serial beta hCG testing. Correct Serial beta hCG testing is part of the protocol for treatment with methotrexate. It is used to ascertain whether a second dose of methotrexate is required. Whether the second dose is given depends on whether the levels of beta hCG are diminishing. Incorrect Awarded 0.0 points out of 1.0 possible points. Page 9 1. A nursing student is being precepted by the RN. The RN looks in Darlene’s chart and confirms with Darlene that she has no past medical history of liver or kidney diseases and administers methotrexate as prescribed by the HCP. Methotrexate, as explained to the couple and the student nurse, is a cytotoxic drug that is typically used as a chemotherapy agent. This makes the administration of the medication a high-risk treatment. 2. 15.ID: 6975251822 Which statement made by the nursing student indicates the need for further teaching? A. "When Darlene is outside this weekend, Darlene should wear sunscreen with SPF 30 or higher." This statement is true. Cytotoxic drugs can increase photosensitivity. B. "Darlene should remain in the specified client treatment area while the cytotoxic drug is being infused.” This statement is true. It is important for the RN to be able to assess the client during the entire course of drug infusion. C. "Pregnant nursing staff members should not administer cytotoxic drugs." Correct At this time there is no conclusive evidence that administering cytotoxic drugs increases the risk of birth defects if proper guidelines are followed. D. "Cytotoxic drugs should be disposed of in a cytotoxic container rather than a red biohazard bag.” Incorrect This statement is true. Cytotoxic drugs should not be disposed of in any waste bin other than those solely for cytotoxic drugs and the equipment used in their administration. Incorrect Awarded 0.0 points out of 1.0 possible points. Page 10 1. 2. Physiologic Integrity: Pharmacological & Parental Therapies 16.ID: 6975251811 What are other approved uses of methotrexate? (Select all that apply.) A. Hydatidiform mole. Correct Methotrexate is used to treat trophoblastic neoplasms such as hydatidiform mole. B. Severe psoriasis. Correct Methotrexate is used to treat severe psoriasis that is not responsive to conventional therapies. C. Tuberculosis. Antitubercular agents, such as rifampin, are used to treat tuberculosis. Cytotoxic drugs such as methotrexate would not be an effective treatment. D. ADHD. ADHD is treated with stimulants and nonstimulants. E. Leukemias. Correct Methotrexate is used to treat leukemias. Correct Awarded 1.0 points out of 1.0 possible points. 3. 17.ID: 6975251813 According to the Occupational Safety and Health Administration (OSHA) agency, what personal protective equipment (PPE) should the RN apply while administering methotrexate? A. B. Gloves. Gloves alone are inadequate PPE for cytotoxic drug administration. Gloves and eye shield. While gloves and eye shield are recommended, this is inadequate protection for the administration of a cytotoxic drug. C. Gloves, mask, and eye shield. While gloves, mask, and eye shield are all recommended, this is inadequate protection for the administration of a cytotoxic drug. D. Gloves, mask, eye shield, and gown. Correct OSHA recommends gloves, mask, eye shield, and gown if there is any risk of splashing. Correct Awarded 1.0 points out of 1.0 possible points. 4. 18.ID: 6975251809 What information should the RN give the client before administering methotrexate? (Select all that apply.) A. Vaginal bleeding is not expected. Vaginal bleeding can occur with administration of methotrexate. B. Avoid alcohol until the pregnancy hormone has returned to normal. Correct Increased risk of liver toxicity and fibrosis with use of methotrexate increases with alcohol consumption. C. Avoid pregnancy for at least 6 months. Incorrect After treatment for ectopic pregnancy with methotrexate, a woman should avoid pregnancy for at least 3 months. D. Avoid folic acid. Correct Methotrexate is a folic acid antagonist. Folic acid supplementation would be contraindicated. E. Any unrelieved pain should be assessed by an HCP immediately. Correct Continuing pain could indicate that the treatment was ineffective. F. Double flush the toilet after use. Correct Methotrexate is a cytotoxic drug, and double flushing reduces the risk of contamination. Incorrect Awarded 0.0 points out of 1.0 possible points. 5. 19.ID: 6975251815 The RN leaves to gather supplies and medicines as well as to allow the couple some alone time. When the RN returns, she finds the student nurse in the room with the couple discussing another client’s recent use of methotrexate. What is the RN’s first action? A. The RN should stop the student nurse from disclosing another client’s medical information with the couple. Correct Disclosing another client’s medical information is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and can have severe consequences for the healthcare personnel. B. The RN should share her own knowledge of the other client’s case to normalize Darlene’s experience. The RN should not discuss another client’s case because this is a violation of the Health Insurance Portability and Accountability Act (HIPAA). C. The RN should assess and document the client’s response. Although the RN should document the client’s response, this is not the first choice. D. Do nothing; it is helpful to build an atmosphere of familiarity while preparing to administer methotrexate. The student nurse’s behavior violates the Health Insurance Portability and Accountability Act (HIPAA), which should be discouraged at all times. Correct Awarded 1.0 points out of 1.0 possible points. Page 11 1. Health Promotions: Therapeutic Communication After treatment is initiated, Darlene begins crying and says, “I didn’t know I could be so sad about losing a pregnancy that I didn’t even know about until today.” The RN’s priority at this time is Darlene’s grief related to her pregnancy loss. 2. 20.ID: 6975251805 Which statement supports the interventions for Darlene’s grief? A. "A large plate of liver and onions will make you feel so much better.” This is not a therapeutic response in this situation. B. "When you get pregnant in 3 months, you won’t even remember this happened.” This is not a therapeutic response in this situation. C. "How have you dealt with loss in the past?” Correct This response recognizes that the client is experiencing a loss and encourages her to utilize her existing coping skills and to discuss her feelings. D. "Does your blood pressure always rise when you cry?” This is not a therapeutic response in this situation. Correct Awarded 1.0 points out of 1.0 possible points. Page 12 1. Case Outcome James is a good support for his wife during the treatment with methotrexate. Darlene completes the regimen, and the ectopic pregnancy is resolved without need for surgical intervention. The couple receives grief counseling and has come to terms with the loss of Darlene’s pregnancy. They agree to wait to start a family.