Q&A: PREECLAMPSIA
A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which assessment finding would indicate that the medication should be discontinued? 1.Absence of deep tendon reflexes 2.Respiratory rate of 16 breaths per minute 3.Urinary output of 45 mL during the past hour 4.Decrease in blood pressure from 180/100 mm Hg to 150/90 mm Hg
1.Absence of deep tendon reflexes Rationale: Signs of magnesium toxicity include central nervous system depression. The respiratory system will fail with the absence of deep tendon reflexes if this condition is not corrected. The client should maintain a respiratory rate at or greater than 16 breaths per minute (or per agency protocol), maintain the presence of deep tendon reflexes, and maintain a urinary output greater than 30 mL/hour. A decrease in blood pressure is a positive finding because preeclampsia is accompanied by hypertension. Client Needs: Physiological IntegrityCognitive Ability: Evaluating Test-Taking Strategy(ies):Focus on the subject, adverse toxic effect of magnesium sulfate. Note the words should be discontinued. These words indicate the need to select the option that indicates toxicity. Knowledge that the signs of magnesium toxicity include central nervous system depression will assist in directing you to the correct option.
The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. 1.Assess blood pressure. 2.Check the urine for protein. 3.Assess deep tendon reflexes. 4.Discuss the need for hospitalization. 5.Teach the importance of keeping track of a daily weight.
1.Assess blood pressure. 2.Check the urine for protein. 3.Assess deep tendon reflexes. 5.Teach the importance of keeping track of a daily weight. Rationale: With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition. Client Needs: Physiological Test-Taking Strategy(ies): Focus on the subject, interventions for mild preeclampsia. Assessment of blood pressure, deep tendon reflexes, and for proteinuria have high priority in the care of a client diagnosed with mild preeclampsia, to monitor whether the disease process is progressing. Women usually are not hospitalized with mild preeclampsia but are taught the clinical signs of a worsening condition. Discussing the need for hospitalization would not be a priority unless it is determined that the disease process has progressed.IntegrityCognitive Ability: Analyzing
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1.Monitor for fetal movement. 2.Monitor the maternal blood glucose. 3.Instruct the client to maintain complete bed rest. 4.Instruct the client to restrict dietary sodium and any food items that contain sodium.
1.Monitor for fetal movement. Rationale: A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary. Cognitive Ability: Applying Test-Taking Strategy(ies):Note the strategic word, priority. Use the ABCs-airway, breathing, and circulation-to assist in directing you to the correct option.
List in order of priority the actions the nurse should take when a client in labor is experiencing eclampsia? 1.Remain with the client . 2.Monitor fetal heart rate patterns. 3.Administer medications to control seizure. 4.Document the occurrence, client's response, and outcome. 5.Insert an oral airway after the seizure ends and suction the client's mouth 6.Ensure the airway is open, turn on her side, and provide 8 to 10 L/min of oxygen.
123456 1. Remain with the client 2. Ensure the airway is open, turn on her side, and provide 8 to 10 L/min of oxygen. 3. Monitor fetal heart rate patterns. 4. Administer medications to control seizure. 5. Insert an oral airway after the seizure ends and suction the client's mouth. 6. Document the occurrence, client's response, and outcome. Rationale: If eclampsia occurs, the nurse remains with the client and calls for help. The nurse ensures an open airway. If the client is not on her side already, the nurse attempts to turn the client on her side. The side-lying position permits greater circulation through the placenta and may help to prevent aspiration. The nurse administers oxygen by face mask at 8 to 10 L/min to ensure adequate placental oxygenation. The nurse also notes the time the seizure began and the duration of the seizure and protects the client from injury during the event. The nurse monitors fetal heart rate patterns closely and administers medications as prescribed (magnesium sulfate may be prescribed). After the seizure has ended, the nurse inserts an oral airway to maintain airway patency and suctions the client's mouth as needed. If warranted, the nurse prepares for the delivery of the fetus after stabilization of the client. The nurse documents the occurrence, the client's response, and the outcome. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Test-Taking Strategy(ies):Not the strategic word, priority. Recall that eclampsia indicates that the client is having a seizure. Use knowledge about the interventions for seizures to assist in answering correctly. Visualizing these actions and thinking about safety management will assist in answering.
What intervention is most likely indicated in managing preeclampsia? 1. Blood Transfusion 2. Multiple Vaginal Examinations 3. Antihypertensives 4. Angioplasty 5. High Fowler's Position 6. Lithotomy Position
3. Antihypertensives Patients may be prescribed an antihypertensive to help lower blood pressure. However, ACE inhibitors and angiotensin receptor blockers (ARBs) are contraindicated due to their effects on fetal development.
A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which magnesium level is within the therapeutic range? 1.1 mEq/L (0.5 mmol/L) 2.3 mEq/L (1.5 mmol/L) 3.5 mEq/L (2.5 mmol/L) 4.10 mEq/L (5 mmol/L) Test-Taking Strategy(ies):Focus on the subject, the therapeutic level for the client taking magnesium sulfate. It is necessary to recall that the therapeutic level for this medication is 4 to 7 mEq/L.
3.5 mEq/L (2.5 mmol/L) Rationale: The therapeutic range for magnesium sulfate is 4 to 7 mEq/L (2 to 3.5 mmol/L); 1 mEq/L (0.5 mmol/L) and 3 mEq/L (1.5 mmol/L) are low values and 10 mEq/L (5 mmol/L) is an elevated value. Client Needs: Physiological IntegrityCognitive Ability: Evaluating Test-Taking Strategy(ies):Focus on the subject, the therapeutic level for the client taking magnesium sulfate. It is necessary to recall that the therapeutic level for this medication is 4 to 7 mEq/L.
The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1."I don't like my figure anymore. My clothes are all too tight." 2."I don't like my breasts anymore. These silver lines are ugly." 3."I don't like my stomach anymore. That brown line is disgusting." 4."I don't like my face anymore. I always look like I have been crying."
4."I don't like my face anymore. I always look like I have been crying." Rationale: In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments should not be ignored, the need for follow-up is not urgent. Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the data in the question, the week of this first prenatal visit (week 18). Also, note the strategic word, immediate. Although all of the choices identify a potential alteration in body image, the correct option is the only one that identifies data that could indicate a complication of the pregnancy.
A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1.Urinary output of 20 mL 2.Deep tendon reflexes of 2+ 3.Fetal heart rate of 120 beats/minute 4.Respiratory rate of 10 breaths/minute
4.Respiratory rate of 10 breaths/minute Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus. Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Note the strategic word, most, and note that the nurse is performing assessments every 30 minutes. Recalling the normal and abnormal assessment findings will direct you to the correct option. Also, use of the ABCs-airway, breathing, and circulation-will direct you to option 4.
The nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1.The magnesium sulfate is effective. 2.The infusion rate needs to be increased. 3.The woman is experiencing cerebral edema. 4.The woman is experiencing magnesium excess.
4.The woman is experiencing magnesium excess. Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess and toxicity. The infusion rate, therefore, would not be increased. Hyperreflexia indicates increased cerebral edema. Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the subject, that the deep tendon reflexes are absent. Use knowledge of the adverse effects of magnesium sulfate to answer this question. Recall that central nervous system depressant effects occur in magnesium toxicity; this will direct you to option 4.
4. A 34 week pregnant client is seen for a routine prenatal visit. She is asked how she is feeling and tells the nurse "I've had a horrible headache for 2 days and my rings suddenly won't fit on my fingers". What is the prioritynursing action? Select all that apply. A. Obtain a urine sample B. Explain that this is normal in pregnancy C. Assess blood pressure D. Administer an antidiuretic E. Administer Acetaminophen
A. Assess blood pressure Blood pressure should be assessed to see if her blood pressure is elevated, causing the headache and increase in swelling. Another sign of preeclampsia. This is another priority assessment. C. Obtain a urine sample A urine sample should be collected to check for proteinuria since this is a sign of preeclampsia. This is a priority. Administer Acetaminophen Acetaminophen can be suggested for a headache but is not the priority nursing action because we need to assess for preeclampsia with a urine sample and blood pressure. Explain that this is normal in pregnancy This might not be normal and requires further assessment and feelings should not be minimized towards the client. Administer an antidiuretic The edema is a possible sign of worsening preeclampsia. Further assessment should be performed prior to intervention.
A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A. Hydralazine. B. Magnesium sulfate bolus. C. Diazepam. D. Calcium gluconate.
A. Hydralazine. Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.
3. A nurse is caring for a newly admitted 32-week pregnant client with a blood pressure of 150/92, proteinuria, and severe right upper quadrant pain. The nurse knows that which of the following is a possible reason for this? A. Liver inflammation B. Constipation C. Gallstones D. Fetal position
A. Liver inflammation RUQ pain in pregnant clients with signs of preeclampsia is most often caused by liver inflammation. Constipation RUQ pain in clients with signs of preeclampsia is most often caused by liver inflammation, not gallstones. Gallstones Constipation pain most often occurs in the LLQ. Fetal position Fetal positioning could cause discomfort in any quadrant, but RUQ pain in clients with signs of preeclampsia is most often caused by liver inflammation.
1. The nurse is caring for a client who is 36 weeks pregnant with severe preeclampsia who was started on magnesium sulfate. The client seized, and the nurse addressed the seizure appropriately and notified the provider. The client is no longer exhibiting seizure activity and is stable. What is the next priority? A. Preparing for delivery B. Turn mother on right side C. Prepare for emergent delivery and hysterectomy D. Prepare for plasmapheresis
A. Preparing for delivery A client who has progressed from preeclampsia to eclampsia requires delivery as soon as possible. Prepare for emergent delivery and hysterectomy Eclampsia does not require a hysterectomy in addition to the delivery. Prepare for plasmapheresis Plasmapheresis is not indicated in this situation. Turn mother on right side The mother should have been turned to the left side as part of seizure management. The mother does not need to be turned to the right side at this time.
2. A nurse is caring for a 30 week pregnant client that has proteinuria and blood pressures of 142/92. What order should the nurse expect to receive? A. Immediate delivery B. Diuretic C. Strict bed rest D. Magnesium sulfate
D. Magnesium sulfate This is a prophylactic treatment for clients with preeclampsia to prevent seizures. Diuretic This client is preeclamptic and this is not expected management. Immediate delivery At this gestation, they would try to control the BP and monitor further. Magnesium sulfate is our prophylactic treatment. Strict bed rest This is not necessary. We want to treat the blood pressure and prevent seizures.
What best describes the time that preeclampsia is commonly seen? 1. After 20 Weeks of Pregnancy 2. After 18 Weeks of Pregnancy 3. After 16 Weeks of Pregnancy 4. After 12 Weeks of Pregnancy
1. After 20 Weeks of Pregnancy Preeclampsia usually begins after the 20th week of gestation; however, it can appear at any time during pregnancy. It occurs most frequently in the final trimester.
Which of the following is considered a feature of severe preeclampsia? 1. HELLP Syndrome 2. Boggy Uterus 3. Night Sweats 4. Cogwheel Rigidity 5. Fitz-Hugh-Curtis Syndrome 6. Rhabdomyolysis
1. HELLP Syndrome HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is a life-threatening condition likely representing a severe form of preeclampsia, though the etiology remains unclear. It presents with more drastic symptoms and signs of liver inflammation. Patients may complain of epigastric pain or right upper quadrant pain, persistent headache, and blurred vision; symptoms that often precede eclampsia-related convulsions.
Which of the following is considered a feature of severe preeclampsia? 1. Progressive Renal Insufficiency 2. Jaundice 3. Cogwheel Rigidity 4. Agalactorrhea 5. Night Sweats 6. Pruritus
1. Progressive Renal Insufficiency In severe preeclampsia, patients develop progressive renal insufficiency. This is defined as a serum creatinine concentration greater than 1.1 mg/dL, or a doubling of the serum creatinine concentration in the absence of other renal disease.
What intervention is most likely indicated in managing preeclampsia? 1. Antimicrobial Prophylaxis 2. Acetylcholinesterase Inhibitors 3. Labor Induction 4. Lumbar Puncture 5. Terbutaline 6. Corticosteroids
3. Labor Induction Delivery of the fetus and placenta is the only cure for preeclampsia. Depending on the stage of the pregnancy and the severity of the disease, the physician may choose to induce labor. If less than 34 weeks, corticosteroids may be given to facilitate fetal lung maturity in preparation for preterm labor.
What finding is seen in mild preeclampsia? 1. Angioedema 2. Boot-Shaped Heart 3. Internal Hemorrhage 4. Neurodegeneration 5. Skin lesions 6. Hypertension > 140/90
6. Hypertension > 140/90 Mild preeclampsia includes an elevated blood pressure of 140/90 taken on two separate readings at least four to six hours apart.
A nurse is monitoring a patient's reflexes (DTRs) while receiving magnesium sulfate therapy for treatment of preeclampsia. Which assessment finding indicates a cause for concern? A. Bilateral DTRs noted at 2+ B. DTRs response has been noted at 1+ since onset of therapy C. Positive clonus response elicited unilaterally D. Patient reports no pain upon examination of DTRs by nurse
C. Positive clonus response elicited unilaterally Positive clonus response elicited unilaterally is a cause for concern as it suggests a hyperactive response. Typically, there is no pain associated with determination of DTRs so this finding would be considered to be normal, as would bilateral DTRs noted at 2+.Even though DTRs at 1+ indicate a sluggish or decreased response, this finding is unchanged since the initiation of therapy. The nurse would continue to monitor.
Which of the following antihypertensive medications would cause a pregnant woman to have a positive Coombs test result? A. Nifedipine (Procardia) B. Methyldopa (Aldomet) C. Labetalol hydrochloride (Trandate) D. Hydralazine (Apresoline)
B. Methyldopa (Aldomet) A positive Coombs test result can occur in about 20% of patients taking methyldopa (Aldomet). None of the other drugs listed would have this effect.
Which laboratory values would be found in a patient diagnosed with preeclampsia? Select all that apply. A. Hemoglobin 8g/dL B. Platelet count of 75,000 C. LDH 100 units/L D. Burr cells E. BUN 25 mg/dL
B. Platelet count of 75,000 C. LDH 100 units/L E. BUN 25 mg/dL Thrombocytopenia below 100,000, an increase in LDH, and an increase in BUN would be noted. Hemoglobin levels would be increased, but 8 g/dL reflects a decreased level.Burr cells would not be present in preeclampsia but would in HELLP syndrome.
Which of the following is considered a feature of severe preeclampsia? 1. Diarrhea 2. Agalactorrhea 3. High fever 4. Rhabdomyolysis 5. Vision Changes 6. Jaundice
5. Vision Changes Blurry vision, double vision, photophobia, or scotomas may occur as a result of retinal arterial spasms.
Which of the following is considered a feature of severe preeclampsia? 1. Agalactorrhea 2. Rhabdomyolysis 3. Myalgia 4. Spastic Paralysis 5. Boggy Uterus 6. Pulmonary Edema
6. Pulmonary Edema As a complication of hypertension in this disease, patients can develop pulmonary edema. This occurs as a result of increased afterload in the heart, pushing fluid into the lungs.
What intervention is most likely indicated in managing preeclampsia? 1. Acetylcholinesterase Inhibitors 2. Multiple Vaginal Examinations 3. Magnesium Sulfate 4. Lithotomy Position 5. Terbutaline 6. Corticosteroids
3. Magnesium Sulfate Magnesium sulfate, a central nervous system depressant, may be given to prevent or reduce seizure activity. This medication may be continued for 24-48 hours postpartum and be sure to monitor for signs of magnesium toxicity such as flushing, sweating, hypotension, depressed deep tendon reflexes, and central nervous system depression. Keep the antidote calcium gluconate readily available.
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura
4.Evidence of bleeding, such as in the gums, petechiae, and purpura Rationale: Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy. Cognitive Ability: Analyzing
A nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is: A. Hypertension. B. Hyperemesis gravidarum. C. Hemorrhagic complications. D. Infections.
A. Hypertension. Preeclampsia and eclampsia are two noted, deadly forms of hypertension, which is the most common medical complication of pregnancy. A large percentage of pregnant women have nausea and vomiting, but a relative few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy.
A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A. A sleepy, sedated affect. B. A respiratory rate of 10 breaths/min. C. Deep tendon reflexes of 2+. D. Absence of ankle clonus.
B. A respiratory rate of 10 breaths/min. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2+ are a normal finding, as is absence of ankle clonus.
8. The charge nurse for labor and delivery has one assigned client yourself and is responsible for the entire unit. This nurse has just received report on the unit from the previous charge nurse. Which of the following clients is most concerning? A. The 24 year-old client who had a cervical cerclage placed at 14 weeks due to an incompetent cervix B. The 31 year-old client with preeclampsia who previously had proteinuria and BP's higher than 140/90, with new-onset oliguria and RUQ pain C. The 40 year-old client with complete placenta previa D. The 22 year-old client with gestational hypertension whose latest BP was 141/89
B. The 31 year-old client with preeclampsia who previously had proteinuria and BP's higher than 140/90, with new-onset oliguria and RUQ pain The client with preeclampsia appears to be progressing to severe preeclampsia. The provider should be aware of this progression, as it may change the delivery plan. The 40 year-old client with complete placenta previa Complete placenta previa requires a scheduled c-section and the provider would already be aware of this plan, so this client is not the priority. The 22 year-old client with gestational hypertension whose latest BP was 141/89 This client has a blood pressure reading that is consistent with the diagnosis of gestational hypertension. Therefore, this client does not need to be urgently assessed. The 24 year-old client who had a cervical cerclage placed at 14 weeks due to an incompetent cervix Since nothing in the answer provides information to indicate that there is any acute concern or distress, this client can deliver normally.
6. A nurse is assessing a pregnant client for possible preeclampsia. Which symptom would be indicative of this diagnosis? A. Active fetal movement B. Edema in the feet C. Proteinuria D. Seizures
C. Proteinuria A client must have protein in her urine to be diagnosed preeclamptic. Seizures This would indicate progression to eclampsia if the client was already preeclamptic, but seizures alone would not indicate preeclampsia. Active fetal movement This would be a normal finding in pregnancy. If anything, we would expect decreased fetal movement in preeclampsia. Edema in the feet Dependent edema is normal in pregnancy, but in a preeclamptic patient there would be a sudden increase and usually in hands and face.
A pregnant woman who is at 21 weeks of gestation has an elevated blood pressure of 140/98. Past medical history reveals that the woman has been treated for hypertension. On the basis of this information, the nurse would classify this patient as having: A. Preeclampsia. B. Gestational hypertension. C. Superimposed preeclampsia. D. Chronic hypertension.
C. Superimposed preeclampsia. Because this patient already has a medical history of hypertension and is now exhibiting hypertension prior after the 20th week of gestation, she would be considered to have superimposed preeclampsia. Preeclampsia would be the classification in a patient without a history of hypertension who was hypertensive following the 20th week of pregnancy. Gestational hypertension occurs after the 20th week of pregnancy in a patient who was previously normotensive. Even though the patient has chronic hypertension, the fact that she is now pregnant determines that she would be classified as having superimposed preeclampsia.
5. The nurse is assessing a client with mild preeclampsia to see if she has progressed to severe preeclampsia. Which of the following would be associated with the progression of this disease process? Select all that apply. A. Oliguria B. Visual changes C. Right upper quadrant pain D. Elevated liver function tests E. Creatinine 0.04
Elevated liver function tests This is an indication that preeclampsia is progressing. Right upper quadrant pain This, along with oliguria, headache, fetal growth restriction are some of the signs of progression of the condition. Visual changes This is a sign of progressing preeclampsia. Oliguria This is another sign of progressing preeclampsia. Creatinine 0.04 (NOPE) A sign of worsening preeclampsia is an elevate creatinine instead of a decreased creatinine.
Which of the following best defines a characteristic of severe preeclampsia? 1. Hypertension Greater Than 160/100 2. Hypertension > 160/110 3. Hypertension Greater Than 140/120 4. Hypertension Greater Than 170/120 5. Hypertension > 140/90 6. Hypertension > 150/100
1. Hypertension Greater Than 160/100 Severe preeclampsia includes an elevated blood pressure of 160/110 taken on two separate readings within six hours.
What intervention is most likely indicated in managing preeclampsia? 1. Side Lying Position and Bedrest 2. Acetylcholinesterase Inhibitors 3. Antimicrobial Prophylaxis 4. High Fowler's Position 5. Methergine 6. Lumbar Puncture
1. Side Lying Position and Bedrest Bed rest may be recommended, which includes a left side lying position as this increases placental blood circulation.
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.Proteinuria 2.Hypertension 3.Low-grade fever 4.Generalized edema 5.Increased pulse rate 6.Increased respiratory rate
1.Proteinuria 2.Hypertension Rationale: The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions. Cognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the subject, the classic signs of preeclampsia. Thinking about the pathophysiology associated with preeclampsia will direct you to the correct options. Remember that the two classic signs of preeclampsia are hypertension and proteinuria.
The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching? 1."It decreases the frequency and duration of uterine contractions." 2."It increases acetylcholine, blocking neuromuscular transmission." 3."It decreases the central nervous system activity, acting as an anticonvulsant." 4."It produces flushing and sweating due to decreased peripheral blood pressure."
2."It increases acetylcholine, blocking neuromuscular transmission." Rationale: Magnesium sulfate produces flushing and sweating because of decreased peripheral blood pressure. It decreases the frequency and duration of uterine contractions and decreases central nervous system activity, acting as an anticonvulsant. Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission. Client Needs: Physiological IntegrityCognitive Ability: Evaluating Test-Taking Strategy(ies):Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Reading each option carefully and recalling that this medication decreases central nervous system activity will assist in directing you to the correct option.
The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1.Administer oxygen by face mask. 2.Clear and maintain an open airway. 3.Administer magnesium sulfate intravenously. 4.Assess the blood pressure and fetal heart rate.
2.Clear and maintain an open airway. Rationale: The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow. Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Note the strategic word, first. Then use the ABCs-airway, breathing, and circulation-to answer the question. Remember that the airway is typically the first priority.
A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1.Restrict food and fluids. 2.Reduce external stimuli. 3.Monitor blood glucose levels. 4.Maintain the client in a supine position.
2.Reduce external stimuli. Rationale: The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs. Cognitive Ability: Creating Test-Taking Strategy(ies):Focus on the subject, interventions for a client with severe preeclampsia. Recalling that the client is at risk for seizures will assist in directing you to the correct option.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1.Proteinuria of 3 + 2.Respirations of 10 breaths per minute 3.Presence of deep tendon reflexes 4.Urine output of 20 mL in an hour 5.Serum magnesium level of 4 mEq/L (2 mmol/L)
2.Respirations of 10 breaths per minute 4.Urine output of 20 mL in an hour Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3 + is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L). Cognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the subject, magnesium toxicity. Eliminate option 3 first because it is a normal finding. Next, eliminate option 5, knowing that the therapeutic serum level of magnesium is 4 to 7.5 mEq/L (2 to 3.75 mmol/L). From the remaining options, recalling that proteinuria of 3+ would be noted and expected in a client with preeclampsia will direct you to the correct options.
A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? 1.Scotomas are present. 2.Seizures do not occur. 3.Ankle clonus is noted. 4.The blood pressure decreases.
2.Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia. Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Client Needs: Physiological IntegrityCognitive Ability: Evaluating Test-Taking Strategy(ies):Note the strategic word, effective. Recalling that magnesium sulfate is an anticonvulsant and thinking about its actions and purpose will direct you to the correct option.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. 1.Proteinuria of 3+ 2.Urine output of 20 mL in an hour 3.Presence of deep tendon reflexes 4.Respirations of 10 breaths/minute 5.Serum magnesium level of 4 mEq/L (2 mmol/L)
2.Urine output of 20 mL in an hour 4.Respirations of 10 breaths/minute Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 mL per hour. Proteinuria of 3+ is an expected finding in a client with preeclampsia. Presence of deep tendon reflexes is a normal and expected finding. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L (2 to 3.75 mmol/L). Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the subject, magnesium toxicity. Eliminate option 3 first because it is a normal finding. Next, eliminate option 5, knowing that the therapeutic serum level of magnesium is 4 to 7.5 mEq/L (2 to 3.75 mmol/L). From the remaining options, recalling that proteinuria of 3+ would be noted and expected in a client with preeclampsia will direct you to the correct options.
A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? 1.A private room across from the elevator 2.A semiprivate room across from the nurses' station 3.A private room 2 doors away from the nurses' station 4.A semiprivate room with another client who enjoys watching television
3.A private room 2 doors away from the nurses' station Rationale: A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care. Client Needs: Safe and Effective Care EnvironmentCognitive Ability: Analyzing Test-Taking Strategy(ies):Note the strategic words, most appropriate. Eliminate options 2 and 4 first because they are comparable or alike. Recalling that a quiet environment in which stimuli can be minimized is most important will direct you to the correct option.
A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the primary health care provider (PHCP). The nurse should tell the woman to call the PHCP if which occurs? 1.Urine test is negative for protein. 2.Fetal movements are more than 4 per hour. 3.Weight increases by more than 1 pound in a week. 4.The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.
3.Weight increases by more than 1 pound in a week. Rationale: The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (3 or fewer movements per hour) may indicate fetal compromise and should be reported. Client Needs: Health Promotion and MaintenanceCognitive Ability: Applying Test-Taking Strategy(ies): Focus on the client's diagnosis, mild preeclampsia in the client in the third trimester, and note the subject, signs that need to be reported. Eliminate options 1, 2, and 4 because these options indicate normal findings.
The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priorityitem should the nurse obtain? 1.Tongue blade 2.Percussion hammer 3.Potassium chloride injection 4.Calcium gluconate injection
4.Calcium gluconate injection Rationale: Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate. Client Needs: Physiological IntegrityCognitive Ability: Applying Test-Taking Strategy(ies):Note the strategic words, highest priority, and focus on the data in the question. Recall that the percussion hammer would identify the decrease in deep tendon reflexes but that the calcium gluconate is required to treat the life-threatening condition that can occur.
The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? 1.Urinary output has increased. 2.Dependent edema has resolved. 3.Blood pressure reading is at the prenatal baseline. 4.The client complains of a headache and blurred vision.
4.The client complains of a headache and blurred vision. Rationale: If the client complains of a headache and blurred vision, the PHCP should be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings. Cognitive Ability: Analyzing
9. Which of the following clients would be at high risk of developing pre-eclampsia during pregnancy? Select all that apply. A. A client who is married B. A client who is pregnant with twins C. A client who is overweight D. A client who is 40 years old E. A client who is pregnant with her third child
B, C, D A client who is 40 years old Pre-eclampsia is a state that develops during pregnancy in which a mother has high blood pressure and starts losing protein into the urine. The situation can cause harm to both the mother and the baby. Advanced maternal age is one of the factors that increase the risk of a pregnant woman developing pre-eclampsia. A client who is overweight Obesity in the mother increases the risk for pre-eclampsia. A client who is pregnant with twins A client pregnant with multiple babies is at increased risk for pre-eclampsia. A client who is married This is unrelated to pre-eclampsia risk. Client who is pregnant with her third child Pre-eclampsia is more likely to develop with the first child than consecutive pregnancies.
With regard to preeclampsia and eclampsia, nurses should be aware that: A. Preeclampsia is a condition of the first trimester; eclampsia is a condition of the second and third trimesters. B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain. C. The causes of preeclampsia and eclampsia are well documented. D. Severe preeclampsia is defined as preeclampsia plus proteinuria.
B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain. Vasospasms diminish the diameter of blood vessels, which impedes blood flow to all organs. Preeclampsia occurs after week 20 of gestation and can run the duration of the pregnancy. The causes of preeclampsia and eclampsia are unknown, although several have been suggested. Preeclampsia includes proteinuria; severe cases are characterized by greater proteinuria or any of nine other conditions.
A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: A. Blood pressure is reduced to prepregnant baseline. B. Seizures do not occur. C. Deep tendon reflexes become hypotonic. D. Diuresis reduces fluid retention.
B. Seizures do not occur. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. A temporary decrease in blood pressure can occur but is not the purpose of administering this medication. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.
Nurses should be aware that HELLP syndrome: A. Is a mild form of preeclampsia. B. Can be diagnosed by a nurse alert to its symptoms. C. Is characterized by hemolysis, elevated liver enzymes, and low platelets. D. Is associated with preterm labor but not perinatal mortality.
C. Is characterized by hemolysis, elevated liver enzymes, and low platelets. The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. It is difficult to identify, because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased with HELLP syndrome, and so is perinatal mortality.
10. A nurse is caring for a pregnant mother who has preeclampsia. Based on the nurse's knowledge of this condition, the nurse understands that the condition could affect the baby by causing which of the following potential complications? A. Premature birth B. Polyhydramnios C. Hypoglycemia D. Macrosomia
Premature birth Preeclampsia is a condition that occurs during pregnancy; it is characterized by very high blood pressure and increased excretion of protein into the urine. It typically occurs after 20 weeks' gestation and can continue for up to 6 weeks after delivery. Preeclampsia affects blood flow to the uterus and placenta, which can lead to multiple complications. A mother with preeclampsia is at higher risk of having a premature baby. Other potential fetal complications include intrauterine growth retardation, impaired oxygenation, and even death. Hypoglycemia Preeclampsia does not cause this condition. Macrosomia Preeclampsia does not cause this condition. Polyhydramnios Preeclampsia does not cause this condition.
QUICK REVIEW
⏩Overview ->Hypertensive disorder ->Proteinuria ->After 20 weeks gestation Nursing Points ⏩General A woman may or may not be symptomatic but will have elevated blood pressures and proteinuria Blood pressures 140/90 or more x 2, 4 hours apart Or a systolic 160 mmhg or more Or a diastolic of 90 mmhg or more -> So remember 140/90 (mild) and 160/90 (severe) ⏩Assessment So what does this patient look like? -> A sudden increase in edema (hands, feet, face) ->Sudden weight gain (Excess fluid retention) ->Complaints of headache ->Complaints of epigastric or RUQ pain ->Vision changes (Serious symptom of preeclampsia; from swelling and irritation of the brain and the CNS) ->Proteinuria ⏩Fetal assessment Intrauterine growth restriction (IUGR) Placental blood flow is not at its best ⏩Therapeutic Management ->Delivery of the baby is the only cure ->Magnesium sulfate is given prophylactically ->Seizure prevention ->Some antihypertensive drugs might be given to manage BP ⏩Nursing Concepts Reproduction Perfusion ⏩Patient Education ->Call MD if nausea, vision changes, headaches, epigastric pain or increased swelling occur ->Perform daily kick counts ->Home BP checks
7. A nurse is caring for a client with preeclampsia that is suffering from some vision changes. What is the bestexplanation by the nurse of what caused this? A. Central nervous system swelling B. Retinopathy that will resolve with delivery of the infant C. Normal pregnancy vision changes D. Uncontrolled diabetes
A. Central nervous system swelling Vision changes are a serious side effect of preeclampsia from central nervous system swelling due to poor protein metabolism and hypertension. Normal pregnancy vision changes Vision changes are a sign that preeclampsia is worsening from CNS swelling. Uncontrolled diabetes Vision changes are a sign that preeclampsia is worsening from CNS swelling, there is no mention of the client being diabetic. Retinopathy that will resolve with delivery of the infant This is not a true diagnosis. The client is experiencing CNS swelling.
What finding is seen in mild preeclampsia? 1. Dysuria 2. Orotic Aciduria 3. Proteinuria or End-Organ Dysfunction 4. Paroxysmal Nocturnal Hemoglobinuria (PNH) 5. Myoglobinuria 6. Nocturia
3. Proteinuria or End-Organ Dysfunction A dipstick reading of 1+ or 2+ indicating protein in the urine confirms mild preeclampsia. Due to elevated blood pressure, patients can develop other end-organ dysfunction as well, including headache, vision disturbances, dyspnea, abdominal pain, edema and altered mental status.
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1.Assess for signs and symptoms of labor. 2.Assess the client's temperature every 2 hours. 3.Schedule a daily ultrasound to assess fetal movement. 4.Schedule a nonstress test every 4 hours to assess fetal well-being.
1.Assess for signs and symptoms of labor. Rationale: As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours. Client Needs: Physiological IntegrityCognitive Ability: Analyzing Test-Taking Strategy(ies):Note the strategic word, priority. Use the steps of the nursing process to answer the question. Assessment is the first step; therefore, eliminate options 3 and 4. Regarding the remaining options, knowing that the client is not at high risk for infection will assist in directing you to the correct option.
The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply 1.Flushing 2.Hypertension 3.Increased urine output 4.Depressed respirations 5.Extreme muscle weakness 6.Hyperactive deep tendon reflexes
1.Flushing 4.Depressed respirations 5.Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. Cognitive Ability: Analyzing Test-Taking Strategy(ies):Focus on the subject, adverse effects of magnesium sulfate. Recalling that this medication is a central nervous system depressant and relaxes smooth muscle will assist you in choosing the correct options.
The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. 5.Allow out-of-bed activity as tolerated.
1.Keep the room semi-dark. 2.Initiate seizure precautions. 3.Pad the side rails of the bed. 4.Avoid environmental stimulation. Rationale: Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.Client Needs: Physiological IntegrityCognitive Ability: Creating Test-Taking Strategy(ies):Note the subject, care of the client with severe preeclampsia. Focus on the client's diagnosis and its pathophysiology. Keep in mind the goal of care with this client, to prevent a seizure. This will assist in directing you to the correct options.Color Key: