ATI Real Life 4.0 Preeclampsia
Nurse Morgan is reviewing prescriptions from Dr. Hunt. For which of the following manifestations should she plan to monitor following administration o hydralazine (Apresoline)? Polyuria Tachycardia Dry mouth Hyperglycemia
Following administration of hydralazine , the nurse should monitor for alterations in blood pressure and tachycardia
Nurse Morgan is reviewing Ms. Klein's laboratory test results. Which of the following findings should Morgan discuss with Ms. Klein regarding her worsening condition? Decreased uric acid Decreased lactate dehydrogenase (LDH) Increased proteinuria Increased platelets
Protein increases with worsening of preeclampsia
Nurse Morgan is preparing to administer magnesium sulfate IV at 2g/hr. Available is magnesium sulfate 40g/1000mL lactated ringers. Morgan should set the IV pump to deliver how many mL/hr? (Round answer to the nearest whole number)
2÷40 x 1000= 50mL per hour
Nurse Morgan is preparing to administer hydralazine 5mg IV bolus. Available is hydralazine 20mg/dL. How many mL should Morgan administer? (Round answer to the nearest hundredth)
5 ÷ 20 = 0.25mg
Nurse Morgan is administering IV magnesium sulfate to Ms. Klein. Which of the following manifestations indicates Ms. Klein is experiencing magnesium toxicity? a) respirations 11/min b) 4+ deep tendon reflexes c) skin pallor d) urinary output of 60 mL/hr
A respiratory rate of less than 12 per minute is an idication of magnesium toxicity. The nurse should report this manifestation to the provider.
Nurse Alex is reviewing the EMRs in preparation to transfer Ms. Kline to the maternal newborn unit. Use the SBAR format to prepare a transfer report.
S= 25 yr old female, gravida 1, para 0, 27 weeks gestation. Came to the emergency department this morning at 0800 B= Reports siudden weight gain , and a new onset of nausea and vomitting, also lurred vision and headavhe. She says she had breakfast this moring but vomited soon after eating A+ Vital Signs: T37.0 P92, R22, BP 162/88, O2 sat 97%, urine protien 1+, deep tendon reflexes 3+, reports right upper quadrant pain, nausea and vomiting and blurred vision with a headache R= Recommendation is to transfer her to maternal newborn unit.
Nurse Morgan prepares to call Dr. Hunt and give a report. Which of the following is the most important clinical data for Morgan to include in the SBAR report? a) urine protein 1+ b) epigsatric pain c) absence of vaginal bleeding d) elevated blood pressure
The elevated blood pressure is the priority clinical finding to include int he SBAR report. The greatest risk to the client and her fetus is impaired tissue perfusion to the placenta and vital organs secondary to arteriolar vasospasm
Nurse Morgan completes an admission assessment for Ms. Klein. Based on the assessment, which of the following is the priority nursing intervention at this time? a) initiate seizure precautions b) inset an indwelling urinary catheter c) monitor Ms. Klein's I&O d) apply antiembolism stockings
The greatest risk to the client and fetus is injury from seizures an resulting hypoxemia. The priority intervention is to initiate seizure precautions.
Nurse Morgan recognizes Ms. Klein is experiencing variable decelerations of the fetal heart rate. Which of the following nursing interventions should Morgan take at this time? administer oxygen via nasal cannula at 2 L/min elevate Ms. Klein's legs prepare Ms. Klein for immediate cesarean birth change Ms. Klein's position
The nurse should change the client's position to a lateral or knee-chest position to attempt to improve uteroplacental perfusion
Nurse Morgan is preparing to teach Ms. Klein about delivery by C-section. Which of the following should Morgan include in the teaching? (Select all that apply) "You will receive pain medication following the procedure" "Monitoring of the fetal heart will continue" "You will receive antiemetic medications" "Your spouse will give informed consent" "I will review options for anesthesia with you"
The nurse should include administration of pain medications and antiemetics and continued fetal heart rate in the preoperative teaching.
Nurse Morgan reviews the lab test results for Ms. Klein. Which of the following findings confirms a diagnosis of severe preeclampsia? Aspartate aminotransferase (AST) 75 units/ L Platelets 158,000/mm3 Hemoglobin 16g/dL Urine protein 1+
This liver enzyme is significantly elevated and is consistent with a diagnosis of severe preeclampsia.