HESI: Preeclampsia

The client's spouse asks if some friends can visit now that the baby has been born. Which response by the nurse is most appropriate?

"She is still at risk for complications, so family members may visit briefly."

At 0930 the client'a spouse rings the call bell and yells, "Come quickly, she is shaking all over!" The nurse determines that the client is experiencing an eclamptic seizure Which nursing intervention takes priority?

Turn the client onto her side and place a pillow behind her to stabilize the position. Aspiration is the leading cause of maternal morbidity and mortality after an eclamptic seizure. By turning the client to a lateral position and using a pillow to hold that position, the nurse can ensure that a patent airway is maintained, the aspiration of vomitus is minimized, and supine hypotension is prevented.

The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced nurse?

A 35-year-old gravida 3, para 2, with HELLP syndrome. This client is the most critical among this group of clients and is at the highest risk for morbidity and mortality. HELLP syndrome occurs in only 2% to 12% of clients with severe preeclampsia.

If the nurse observes that a client on magnesium sulfate has 40 mL in the urimeter in 2 hours, her respiratory rate is 10 breaths/minute and her DTR's are 4, which medication should the nurse prepare to administer?

Calcium gluconate. If magnesium toxicity is suspected, the magnesium should be discontinued immediately and the nurse should prepare to administer calcium gluconate. The symptoms of magnesium toxicity include: blood pressure: systolic ≥160 mm Hg or diastolic ≥110 mm Hg, respiratory rate: <12 breaths/min, urinary output: <25-30 mL/hr, presence of headache, visual disturbances, decrease in level of consciousness, or epigastric pain, increasing severity or loss of DTRs, increasing edema, proteinuria.

What information should be included in the client and family teaching about magnesium sulfate?

Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. If renal function declines, not all of magnesium sulfate will be excreted, resulting in magnesium toxicity.

The client remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released her from the postanesthesia care unit. Which room and nursing staff assignments should be made for the client?

Move the client to a quiet room close to the nursing station in Labor and Delivery, and assign one nurse to care for her. A quiet room with one-to-one care is the most appropriate assignment. Clients with preeclampsia, even if they have not seized prior to birth, remain at risk for seizures. Magnesium is continued for at least 12 to 24 hours, based on the client's condition. Close assessment, including frequent vital sign monitoring, reflex checks, and I&O measurement is necessary. In addition, since magnesium relaxes smooth muscle, the client is at greater risk for postpartum hemorrhage.

To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain?

Prenatal blood pressure readings.

The nurse performs a nonstress test to evaluate fetal well-being. The client is getting nervous and anxious with the situation. She asks the nurse why she is doing a nonstress test. What is the nurse's best response?

It evaluates the heart rate of the fetus in response to its own movements. The basis for the nonstress test is that the normal fetus with an intact central nervous system (CNS) will respond to fetal movements with an increased heart rate (episodic accelerations). A reactive test is one in which the fetus displays at least two accelerations of 15 beats per minute that last for 15 seconds in a 20-minute period in the presence of a normal baseline rate and moderate variability.

he client's spouse offers to sign the consent forms for her since she isn't feeling well right now. Which response by the nurse is correct?

"The client should sign the consent forms herself since she is the one receiving the care." The client is the person who should sign the consent forms. By validating the client's role in informed consent and the decision-making process, the nurse enhances client empowerment.

The client's sister is very concerned about the swelling in her sister's face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider (HCP) will prescribe some water pills (diuretics) to help get rid of the excess fluid. Which response by the nurse is correct?

"I would be happy to explain to you about the effect of diuretics on pregnancy." The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood volume. In the case of the preeclamptic client, this is particularly dangerous because the disease has already caused a volume deficit. In addition, the diuretics disrupt normal electrolyte balance and stress kidneys that are already compromised by preeclampsia. The only time they are used is if the preeclamptic client also has heart failure, but this client has no symptoms of heart failure.

Prior to initiating the HCP's prescription, the nurse must first obtain consent for vaginal and cesarean birth, analgesia and anesthesia, and blood transfusion.The HCP prescribes this plan of care for the client: Obtain permits for vaginal birth, cesarean birth, analgesia/anesthesia, and blood transfusion. Start on magnesium sulfate (4 g bolus over 20 min, then 1 g/hr per pump) per unit protocol. Follow standing magnesium sulfate protocol (may vary by hospital):Primary IV: Lactated Ringer's solutionTotal fluid volume: 150 mL/hourInsert Foley catheter with urimeter attachment for hourly I&OBed restVital signs & DTRs hourly after stabilized on magnesium sulfateContinuous uterine and fetal monitoringCalcium gluconate at bedside Begin oxytocin induction per protocol The client asks the nurse why she is getting magnesium sulfate. What is the the nurse's best response?

"It is a central nervous system depressant given to prevent seizures." Magnesium sulfate depresses the CNS by interfering with the neuromuscular junction. It is given to prevent or control eclamptic seizures.

While the nurse is awaiting the lab results to determine if the client has elevations in liver function, diminished kidney function, or altered coagulopathies, which questions should the nurse ask her?

-"Do you have a Dizziness? -Do you have blurry vision?" -"Do you have abdominal pain" -"Do you have shortness of breath or chest discomfort?"

Using the Maternal Fetal Triage Index, triage the following clients in order from 1 to 5, with 1 being the highest priority and 5 being the lowest. (Rank in priority from 1 to 5 with 1 being the highest priority and 5 being the lowest priority.)

1. A primigravida has been laboring without complications, but calls the desk to say her "water broke and something is hanging out down there." 2. A G4P3 client arrives in Labor & Delivery saying her HCP diagnosed her with placenta previa and she has been having contractions and spotting. 3. A G1P0 mother has labored for 20 hours and has only progressed to 3 cm. The HCP determines it is cephalopelvic disproportion and prescribes a cesarean birth. 4. A primigravida due in 3 weeks comes to Labor & Delivery after having a bladder infection, and now her labor has started. 5. A G2P1 client arrives in Labor & Delivery with her partner and says she is scheduled for an induction because she is 1 1/2 weeks past her due date

The HCP prescribes an IV infusion of magnesium sulfate of 1 gram/hour after the bolus has been completed. The pharmacy sends an IV bag with 40 grams/1000 mL. What rate should the nurse set the IV pump?

25 1000/4

The client has been prescribed a 4 gram bolus of magnesium sulfate to run over 20 minutes. It arrives from the pharmacy diluted in 250 mL of normal saline. What rate does the nurse set the IV pump to run the bolus?

250 mL X 60 minutes = 15,000 = 750mL Available 20 minutes

At 0630 the nurse calls to report to the HCP, who prescribes the following: admit to labor and delivery, bed rest with bathroom privileges, IV D5LR at 125 mL/hr, oxytocin 2 mu/min, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital signs, and DTRs. After the nurse establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000 mL D5LR. The prescription from the HCP is oxytocin 2 mU/min to augment labor. What is the drip rate for the oxytocin?

6 1/1000 x 2mu/1hr =2000/20000 =0.10 x 60 min=6mL/hr

The nurse asks the client if the HCP has discussed the labor and delivery processes, potential complications, and the management of those complications with her and if she understands them. The client replies, "I think so," and then asks for a pen. Which action should the nurse take?

Ask the client to explain what she understands about the procedures she is undergoing. It is the responsibility of the nurse to ascertain what the client understands about the procedures and the potential risks associated with those procedures. If the client does not understand, the nurse must contact the HCP to clarify further for the client.

The RN is aware that continued magnesium sulfate puts the client at risk for postpartum hemorrhage even though oxytocin is infusing. The nurse is aware that continued magnesium sulfate puts the client at risk for postpartum hemorrhage even though oxytocin is infusing. The nurse recognizes that which medication is safest for the cient if a second drug is needed to treat postpartum hemorrhage?

Carboprost tromethamine. This medication, a derivative of prostaglandin F2 alpha, may be administered intramuscularly, intramyometrially at cesarean birth, or intraabdominally after vaginal birth. When given intramuscularly in the postpartum period, the usual dose is 25 mg every 15 to 90 minutes for up to 8 doses. This drug may be used with the hypertensive client.

Preeclampsia develops after 20 weeks' gestation in a previously normotensive woman. Elevated blood pressure is frequently the first sign of preeclampsia. The client has a headache and blurred vision and also develops proteinuria. While no longer considered a diagnostic measurement of preeclampsia, generalized edema of the face, hands, and abdomen that is not responsive to 12 hours of bed rest is often present. Preeclampsia progresses along a continuum from mild to severe preeclampsia to eclampsia. A client may present to the labor unit anywhere along that continuum. What is the pathophysiology responsible for the client's complaint of a pounding headache and the elevated DTRs?

Cerebral edema. As fluid leaks into the extravascular spaces, organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increased deep tendon reflexes, and clonus.

At 0800, physical assessment and labs reveal the following: the client is still reporting a headache, but the epigastric pain has slightly decreased. While the client is resting in a left lateral position, the vital signs are BP 146/94 mmHg, P 75 beats/min, and R 18 breaths/min. Hyperreflexia continues with one beat of clonus. The baseline fetal heart rate is 140 with moderate variability and no decelerations. Since completion of a reactive nonstress test, no further accelerations have occurred.Lab results include the following: hemoglobin 14.2 g/dl (8.81 mmol/L); hematocrit 42.5% (0.425 L/L ); platelets, 120,000 mm3 (12 G/L); aspartate aminotransferase (AST), slightly elevated; alanine aminotransferase (ALT),normal for pregnancy; 0 burr cells on slide; clotting studies normal for pregnancy.he HCP diagnoses the client with Gestational Hypertension and Preeclampsia With Severe Features. If the client had HELLP syndrome, which lab results would the nurse expect to see?

Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased platelets. All of these indicate HELLP syndrome. HELLP stands for: hemolysis (H), evidenced by burr cells or an elevated bilirubin level; elevated liver enzymes (EL), evidenced by elevated AST and ALT; and decreased platelets.

Which technique should the nurse use when evaluating the client's blood pressure while she is on bed rest?

Have the client lie in a lateral position and take the blood pressure on the dependent arm. The lateral position supports placental perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the blood pressure should be taken in that arm. This more closely approximates arterial pressure. Using the arm on the opposite (upper) side will falsely reduce the measurement.

The client gives birth vaginally to a baby girl. The Apgar score is 2 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes. After the client and her spouse hold the baby for a few minutes, the baby is taken to the neonatal intensive care unit (NICU) for observation. The placenta is delivered spontaneously, and the client remains in the labor/delivery/recovery room. The NICU nurse anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate?

Hyporeflexia and respiratory depression. Because magnesium sulfate crosses the placenta, the newborn can develop toxic levels of magnesium. Neonatal hypermagnesemia manifests as hypotonia and a marked decrease in respiratory rate. This is not to be confused with irregular respirations, which are common in all infants. Hypermagnesemia may be treated with calcium and exchange transfusion with citrated blood and/or assisted mechanical ventilation until serum levels are normal. As with the mother, magnesium is cleared through the kidneys.

For which complication is the client most at risk following the epidural with a local anesthetic, such as bupivacaine or ropivacaine?

Hypotension. Hypotension occurs as a result of the sympathetic blockade. It is a common occurrence after an epidural if the mother is not adequately pre-hydrated or already has an impaired fluid volume, as the client does due to her preeclampsia. It can be prevented by adequate pre-load. For clients at risk for fluid overload, the use of central monitoring is indicated. The use of the side-lying position will also aid in preventing hypotension due to vena cava compression that occurs in the supine position. Ephedrine is the vasopressor of choice should severe hypotension occur. However, it is given only after fluid volume replacement, oxygen administration, and lateral positions have been implemented but were unsuccessful.

The client is lying on her left side. Oxygen is being administered via mask at 10 liters per minute. Both of these actions incorporate principles of intrauterine resuscitation. Intrauterine resuscitation is directed toward improving uterine blood flow and increasing maternal oxygenation and cardiac output. What should the nurse do next to ensure intrauterine resuscitation?

Implement a prescribed fluid bolus to improve maternal blood volume. A bolus of non-dextrose IV fluid (normal saline or Ringer's lactated) will increase the maternal fluid volume, thereby improving blood flow and oxygenation to the fetus. The client already has a decrease in volume, secondary to her preeclampsia. For the client, the bolus will be carefully controlled because of her decreased kidney function.

After the seizure ends, the nurse assesses the status of membranes, which may have ruptured during the seizure, as well as the fetal heart rate and the contraction status.The nurse observes the following pattern on the external fetal monitor: Contractions occur every 3 minutes and last 60 seconds. Baseline fetal heart rate is 130 beats per minute. Minimal variability. At peak of each contraction, the fetal heart rate gradually decreases to 117 beats per minute and then returns to the baseline 15 seconds after contraction ends. At 1030 the nurse notes that the client's urine output is 30 mL/hr and spontaneous rupture of membranes (SROM) has occurred with clear amniotic fluid. The nurse recognizes what type of periodic fetal heart rate change is occurring?

Late decelerations. Late decelerations are caused by uteroplacental insufficiency. Late decelerations are characterized by a gradual decrease from the baseline that begins after the contraction has started and does not return to baseline until after the contraction ends. Persistent late decelerations usually indicate fetal hypoxemia and can progress to hypoxia and acidemia. In the client's case, the late decelerations stem from the eclamptic seizure, during which the oxygen supply to the mother and fetus was compromised.

No further seizures occur, and at 1100 the nursing assessment reveals that the client is groggy but responsive with hand grasp weak bilaterally. Her DTRs are 1+ biceps, triceps, and patellar with no ankle clonus. Vital signs are BP 138/88, P 82, and R 14.The most recent magnesium level is 8 g/dL. The hourly intake is 175 mL, and the output is now 30 mL. The baseline fetal heart rate via external monitor is 130 with minimal variability. There are no accelerations, and the decelerations have ceased. SROM occurred with the seizure, and the fluid was clear.Contractions are occurring every 3 minutes and lasting 60 seconds. The contractions are strong to palpation. Vaginal exam by the HCP reveals that the cervix is dilated 7 cm and is 100% effaced and that the fetal head is at 0 station.The HCP makes the decision to continue labor rather than perform a cesarean section because both mother and baby are stabilizing and the cervix is changing. The client is crying with each contraction and requests something for pain. After consultation with the anesthesia provider, the HCP prescribes an epidural using a local anesthetic agent as opposed to an opioid analgesic. How should the client be positioned to receive the epidural?

Modified lateral recumbent position with legs flexed and back arched. This position eases the placement of the catheter into the epidural space. Keeping her side lying will help maintain perfusion to the placenta and fetus.

Admission assessment by the nurse reveals the following: today's weight 182 pounds, T 99. 1° F (37.3o C), P 76 beats/min, R 22 breaths/min, BP 138/88 mmHg, 4+ pitting edema, and 3+ proteinuria. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus. The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, short-term variability present, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station. In reviewing the client's history, the nurse is correct in concluding that she is at risk of developing a hypertensive disorder. Which other factors add to her risk of developing preeclampsia?

Nulliparity Familial history. Preexisting medical or genetic condition. Advanced maternal age.

The 0900 assessment reveals the following: Client reports that her headache has decreased slightly, but the epigastric pain has increased. Complaints of scotoma began about 5 minutes ago. Reflexes are 4+ biceps and patellar and 3+ triceps with 3 beats of ankle clonus. Vital signs are T 99° F (37o C), P 80 beats/min, R 19 breaths/min, and BP 144/96 mmHg. The most recent blood magnesium level is 2 g/dL. Intake since admission (at 0600) is 150 mL, and output is 300 mL. The HCP increases the magnesium sulfate prescription to 2 g/hr. Fetal monitor tracing reveals a baseline fetal heart rate in the 120s, minimal variability, no accelerations, and no decelerations. Uterine contractions are occurring every 4 to 5 minutes and they are moderate quality upon palpation. Cervical exam indicates the cervix is now 3 cm dilated and 80% effaced, with the presenting part (cephalic) at -1 station. The client reports mild discomfort with contractions, but she does not want anything for pain at this time. The client's spouse is at the bedside helping her use relaxation breathing through each contraction. The client is in the right lateral position with the head of the bed slightly elevated. She asks why the magnesium sulfate was increased. What explanation should the nurse provide?

The HCP increased the dosage to achieve the level that prevents seizures. The magnesium level is not up to therapeutic range (4 to 7 mEq/L) because it is being excreted from the body.

When evaluating the fetal monitor strip, the nurse notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change?

The fetus has the same magnesium level as the mother's, causing the fetus to be sedated. Because magnesium sulfate crosses the placenta, the baby will have a magnesium level equal to the mother. Although sources differ on the effect that magnesium levels have on long-term variability, many sources do attribute a decrease in long-term variability to magnesium sulfate. Other sources state that magnesium sulfate does not affect fetal heart rate variability in a healthy term fetus whose weight is normal for gestational age. However, this fetus is preterm (36 weeks), and all fetuses of mothers with hypertensive diseases during pregnancy are at risk for intrauterine growth restriction related to poor placental perfusion.

At 1130 the client complains of rectal pressure and an urge to push. She reports no scotoma and no epigastric pain. Her vital signs are T 98.4° F (36.9o C), P 70, R 16, and BP 130/83. DTRs are 1+ biceps and triceps; unable to elicit patellar, no clonus. Intake for the last hour is 150 mL, and output is 30 mL.The baseline fetal heart rate is 120 with minimal variability, positive for accelerations and mild variable decelerations. Strong contractions lasting 70 seconds are occurring every 2 to 3 minutes. The client's cervix is now 10 cm dilated, and the fetal head is at +3 station. The nurse informs the HCP. Because the client is completely dilated and has the urge to push, the nurse reviews the proper pushing technique with the client and her partner. What should the nurse tell the client about pushing effectively?

When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides. This method of pushing utilizes both instinctive, spontaneous pushing and open-glottis pushing. It is physiologically correct in that it utilizes Ferguson's reflex (the urge to bear down), at which time more oxytocin is released from the exterior pituitary to strengthen bearing-down contractions. Exhalation while pushing, limiting the amount of time breath is held, and taking deep breaths in between pushing efforts help maintain adequate oxygenation to the mother and fetus. This technique results in approximately 5 pushes during each contraction and is less likely to overtire the mother. This is in opposition to closed-glottis (prolonged breath-holding while pushing) technique, which may trigger the Valsalva maneuver. If that occurs, the increased intrathoracic and cardiovascular pressures reduce cardiac output and diminish perfusion of oxygen across the placenta, putting the fetus at risk for hypoxia.