SAUNDERS MATERNITY: Gestational Hypertension/Preeclampsia and Eclampsia

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. 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.

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. 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.

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. 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 home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1.Hypertension 2.Low-grade fever 3.Generalized edema 4.Increased pulse rate

1.Hypertension Rationale:A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions. Test-Taking Strategy(ies):Focus on the subject, a sign of preeclampsia. Thinking about the pathophysiology associated with preeclampsia will direct you to the correct option. Remember that hypertension is associated with preeclampsia.

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)

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. 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.

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). 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 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. 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.

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. 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 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 priority item 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. 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.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision for the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3. "I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen and it went away."

1. "My vision for the past 2 days has been really fuzzy." Rationale:Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia. Test-Taking Strategy(ies):Focus on the subject, an indication of worsening gestational hypertension. Read each option carefully, looking for the indication of a worsened condition. Recalling the signs of progressing gestational hypertension and that visual disturbances occur will direct 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. 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.

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. 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 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. 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.

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, 2, 3, 4 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. 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.

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, 2, 3, 5 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. 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.

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.

1, 6, 2, 3, 5, 4 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. 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.

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. 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.

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. 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 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. 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. 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.

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. Test-Taking Strategy(ies):Note the word worsening in the question. Eliminate options 1, 2, and 3 because these options are comparable or alike and indicate normal findings.

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. 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.

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. 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.

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. Test-Taking Strategy(ies):Note the strategic word, most. Focus on the subject, a complication of preeclampsia. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal occurrences in the last trimester of pregnancy.