N144 Week 5 Case Study - Preeclampsia

Question 21 of 30 Which nursing intervention takes priority? Make a note of the time and sequence of the eclampsia seizure. Observe fetal monitor for non-reassuring patterns of fetal heart rate. Turn the client onto her side and place a pillow behind her to stabilize the position. Suction the mouth and oropharynx, and apply oxygen at 10 liters/minute by facemask.

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. This should be done, but another action takes priority. Suctioning should be done only after the seizure ceases. Then oxygen should be applied.

Question 6 of 30 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? (Select all that apply. One, some, or all options may be correct.) Select all that apply "Do you have any dizziness?" "Do you have blurry vision?" "Do you have abdominal pain?" "Do you have cramping in your calf when you flex your leg?" "Do you have shortness of breath or chest discomfort?"

"Do you have any dizziness?" "Do you have blurry vision?" "Do you have abdominal pain?" "Do you have shortness of breath or chest discomfort?" Increased peripheral resistance manifests itself as an elevated blood pressure, causing dizziness. Retinal arterial spasms may cause blurring or double vision, photophobia, or scotoma (spots before the eyes). This is due to the cerebral edema. An increase in microvascular fat deposits within the liver is postulated as one of the causes of abdominal pain. Shortness of breath, chest tightness or discomfort, cough, or O2 saturation less than 95% could be signs or symptoms of pulmonary edema and could indicate worsening of preeclampsia. Cramping in the calf upon flexing the leg could indicate a deep vein thrombosis, not preeclampsia.

Question 4 of 30 Which response by the nurse is correct? "That is a very good idea. I will relay it to the healthcare provider when I call." "I would be happy to explain to you about the effect of diuretics on pregnancy." "Have you by any chance given your sister water pills that belong to someone else?" "I'm sorry, but it is not the family's place to make suggestions about medical treatment."

"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. Although it is caring to offer to relay family concerns to the HCP, the physician will make the decision about treatment. This could be construed as hostile and accusatory. If the nurse believes further assessment is warranted, the nurse should ask the client about any medication she has taken. It is not inappropriate for family members to make suggestions, and this response is not sensitive to the sister's desire to help the client.

Question 12 of 30 The client asks the nurse why she is getting magnesium sulfate. What is the the nurse's best response? "It is a diuretic and it is being given to help get the fluid off." "It is a tocolytic, which means it is being given to stop your labor." "It is a central nervous system depressant given to prevent seizures." "It is an antihypertensive and it will help bring your blood pressure down."

"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. Magnesium sulfate is not a diuretic. Magnesium sulfate is a tocolytic for preterm labor, but in this case it is a CNS depressant to prevent and control eclamptic seizures. While there is some relaxation of blood vessel walls resulting in a slight decrease in the BP, magnesium sulfate is not an antihypertensive. If a pregnant client needs an antihypertensive, the drugs of choice are hydralazine or labetalol.

Question 29 of 30 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? "Absolutely not! Do you want to make her condition worse?" "You are a parent now. You have lots to learn while you're here." "She is still at risk for complications, so family members may visit briefly." "Sure. I know they would love to see the new baby! This is such an exciting time."

"She is still at risk for complications, so family members may visit briefly." This answer gives the client's spouse the facts about her condition (still at risk for complications). This response is both condescending and judgmental. This response is both condescending and judgmental. While it is true that this parent may need to learn how to properly care for the client and new baby, this is not the way to open communication about educational needs. This could compromise the client's safety. She is just a few hours postpartum and less than 5 hours postseizure. As her condition stabilizes, she will be able to assume normal postpartum activities.

Question 18 of 30 Which response by the nurse is correct? "The client does not have to sign the informed consent." "That would be fine. Please read over the forms before you sign." "If the client does not feel like signing, we just wait until she feels better." "The client should sign the consent forms herself since she is the one receiving the care."

"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. If the client does not sign the informed consent, treatment will not be rendered. The spouse is not the proper person to sign the client's forms. The situation is not appropriate to wait until she feels better.

Question 10 of 30 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.) 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. A primigravida has been laboring without complications, but calls the desk to say her "water broke and something is hanging out down there." A primigravida due in 3 weeks comes to Labor & Delivery after having a bladder infection, and now her labor has started. A G4P3 client arrives in Labor & Delivery saying her HCP diagnosed her with placenta previa and she has been having contractions and spotting. 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.

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. Ranking should be 2, 4, 5, 3, 1. The client who says her water broke and something is hanging out most likely has a prolapsed cord which is Priority 1 Stat. The client with placenta previa is Priority 2 Urgent. Client who has labored 20 hours and needs a cesarean is Priority 3 Prompt. The primipara due in 3 weeks is 37 weeks so not preterm and her labor is likely to be slower due to being her first pregnancy, so she is Priority 4 Non-urgent. The client scheduled for an induction is Priority 5 Scheduled. She is not in labor and can wait until the other clients are cared for.

Question 16 of 30 Fill in the blankThe 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? (Enter a whole number, if needed, round to a whole number.) ______ mL/hour

25 mL/hour

Question 5 of 30 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? (Enter the numerical value only. If rounding is required, round to the whole number.) _________ mL/hour

6 20 units = 20,000 mu (Calculate ml/hour, not drops/min)

Question 15 of 30 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? (Enter a whole number, round as needed. ) ______ mL/hour

750 mL/hour

Question 11 of 30 Which client should be assigned to the most experienced nurse? A 15-year-old gravida 1, para 0, with mild preeclampsia. A 35-year-old gravida 3, para 2, with HELLP syndrome. A 23-year-old gravida 2, para 0, with gestational diabetes. A 16-year-old gravida 1, para 0, with preterm labor.

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. While this client (15yo) is certainly high risk, her condition is not the most critical. She does, however, require diligent maternal-fetal monitoring and close observation because her condition can deteriorate rapidly. While this client (23yo) is certainly high risk, her condition is not the most critical. Close monitoring of blood glucose levels, as well as diligent maternal-fetal monitoring is necessary, especially if insulin is needed for glucose control in the intrapartum period. While this client (16yo) is certainly high risk, her condition is not the most critical. She does, however, require diligent maternal-fetal monitoring, especially if she progresses to the point at which she requires the use of tocolytic medications.

Question 17 of 30 Which action should the nurse take? Witness the signatures after the client and her spouse have signed the consent form. Call the HCP to explain all procedures again to the client before asking her to sign. Explain all the procedures and risks, and then ask the client to sign the consent form. Ask the client to explain what she understands about the procedures she is undergoing.

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. It is not clear by the client's answer that she understands the HCP's plan of care. In addition, her spouse does not have to co-sign. This may need to be done eventually, but it is not the most appropriate choice at this point. It is never the role of the nurse to assume responsibility for the explanation of medical or surgical procedures and risks in the consent process.

Question 14 of 30 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? Vitamin K. Corticosteroid. Calcium gluconate. Polystyrene sulfonate.

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. Vitamin K is administered for elevated INR levels. It will not correct magnesium sulfate toxicity. 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. Corticosteroids are anti-inflammatory medications. It will not correct magnesium sulfate toxicity. 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. Polystyrene sulfonate is administered for elevated potassium levels. It will not correct magnesium sulfate toxicity. 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

The RN is aware that continued magnesium sulfate puts the client at risk for postpartum hemorrhage even though oxytocin is infusing. Question 30 of 30 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. Methylergonovine. Ergonovine. Leonurus.

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. An ergot derivative, Methylergonovine is contraindicated for the client with preeclampsia because it increases the blood pressure. An ergot derivative, Ergonovine is contraindicated for the client with preeclampsia because it increases the blood pressure. While this herbal preparation (Leonurus) is recognized as a remedy for postpartum hemorrhage, it is contraindicated in preeclampsia because it is vasoconstrictive. In addition, published evidence of safety and efficacy is lacking.

Question 3 of 30 What is the pathophysiology responsible for the client's complaint of a pounding headache and the elevated DTRs? Severe anxiety. Cerebral edema. Retinal arteriolar spasms. Increased perfusion to the brain.

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. While the client may be very anxious, this is not the pathophysiology involved. These spasms are the cause of blurred vision and scotoma that often accompany worsening of the disease. The decreased perfusion to the brain causes the headaches. The hypovolemia that accompanies preeclampsia decreases perfusion to the major organs.

Question 9 of 30 If the client had HELLP syndrome, which lab results would the nurse expect to see? Elevated hemoglobin and hematocrit without burr cells, elevated liver enzymes, and decreased platelets. Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased platelets. Elevated hemoglobin and hematocrit with burr cells, decreased liver enzymes, and increased platelets. Decreased hemoglobin and hematocrit without burr cells, increased liver enzymes, and increased platelets.

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. Elevated hemoglobin and hematocrit without burr cells are not indicative of 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.

Question 7 of 30 Which technique should the nurse use when evaluating the client's blood pressure while she is on bed rest? Have the client lie supine and take the blood pressure on the left arm. Have the client lie in a lateral position and take the blood pressure on the dependent arm. Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. Have the client stand briefly and take the blood pressure on the right arm.

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. A pregnant client should not lie in the supine position because it puts her at risk for vena cava compression and subsequent supine hypotensive syndrome. While sitting is an appropriate position, the arm should be resting on a surface at heart level. In addition, the client is on bed rest with bathroom privileges, which does not include sitting up in a chair. A standing blood pressure does not provide the most valid reading. In addition, the client is on bed rest with bathroom privileges, which does not include standing at the bedside.

Question 27 of 30 The NICU nurse anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate? Hyperreflexia and poor feeding. Hyporeflexia and irregular respirations. Hyporeflexia and respiratory depression. Hyperreflexia and respiratory depression.

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. This is not the combination of complications expected with elevated magnesium levels (hypermagnesemia). Neonatal hypermagnesemia, although rare, can present as apnea, respiratory depression, lethargy, poor feeding, and hyporeflexia. An interprofessional team skilled in neonatal resuscitation should be available. This is not the combination of complications expected with hypermagnesemia. Neonatal hypermagnesemia, although rare, can present as apnea, respiratory depression, lethargy, poor feeding, and hyporeflexia. An interprofessional team skilled in neonatal resuscitation should be available. This is not the combination of complications expected with elevated magnesium levels (hypermagnesemia). Neonatal hypermagnesemia, although rare, can present as apnea, respiratory depression, lethargy, poor feeding, and hyporeflexia. An interprofessional team skilled in neonatal resuscitation should be available.

Question 25 of 30 For which complication is the client most at risk following the epidural with a local anesthetic, such as bupivacaine or ropivacaine? Hypotension. Spinal headache. Respiratory depression. Elevated temperature.

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. If the dura was accidentally punctured during epidural insertion, the client could develop a postdural puncture headache (spinal headache). However, the client is at greater risk for hypotension. Respiratory depression is more likely to occur when opioid analgesics such as fentanyl, sufentanil, or preservative-free morphine are used. The client receiving these medications should be assessed for respiratory depression hourly for at least 24 hours after the epidural is discontinued. There is some evidence that clients who receive an epidural, especially one lasting more than 12 hours, may have an elevated temperature. However, the client is at greater risk for hypotension.

Question 23 of 30 What should the nurse do next to ensure intrauterine resuscitation? Increase the oxytocin infusion rate to hasten the birth. Elevate the head of the bed 90 degrees to improve cardiac output. Implement a prescribed fluid bolus to improve maternal blood volume. Decrease the magnesium sulfate rate to improve uterine contractility.

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. This fetus is already displaying a nonreassuring fetal heart rate pattern. Increasing the oxytocin will increase uterine contractions that could further stress the fetus. The right or left lateral position most effectively promotes maternal cardiac output, thus enhancing blood flow to the fetus. While it is true that magnesium sulfate can decrease uterine contractility, it should not be decreased. The client is still at risk for seizure, and her magnesium sulfate will be increased or decreased based on magnesium levels and clinical response.

Question 8 of 30 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 measures the oxygen levels of the fetus. Accelerations of the fetal heart rate in response to uterine contractions. It evaluates the heart rate of the fetus in response to its own movements. Late decelerations of the fetal heart rate in response to uterine contractions.

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. Low oxygen levels may alter a nonstress test, but it is not measured with this test. Accelerations that occur with contractions (periodic accelerations) are usually linked to breech presentations and are not the basis for the nonstress test. Late decelerations in response to uterine contractions are the basis for the contraction stress test.

Question 22 of 30 The nurse recognizes what type of periodic fetal heart rate change is occurring? Late decelerations. Early decelerations. Variable decelerations. Transient bradycardia.

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. Early decelerations are the result of fetal head compression. While the decrease in rate and increase to baseline is gradual, it mirrors the contractions, starting as the contraction begins and finishing as the contraction ends. These are benign decelerations and are considered reassuring. Variable decelerations are frequently the result of cord compression. Variable decelerations may occur at any time: before, during, or after contractions. These decelerations display an abrupt onset and often an abrupt recovery. They may be U, V, or W shaped. Some are accompanied by brief accelerations before and/or after the deceleration (a compensatory response to the umbilical cord compression). Bradycardia in the fetus is defined as a baseline of less than 110 beats per minute for a duration of 10 minutes or longer.

Question 13 of 30 What information should be included in the client and family teaching about magnesium sulfate? This medication will be given intramuscular every four hours for 24 hours. Magnesium sulfate may cause hyperactivity, leg cramps, and difficulty sleeping. Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. Magnesium sulfate increases the risk of having seizures and we will need to watch her closely.

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. Magnesium sulfate is rarely given intramuscular, it is difficult to manage the therapeutic range. Magnesium sulfate causes sedation, not hyperactivity. Magnesium sulfate decreases the risk of having seizures.

Question 24 of 30 How should the client be positioned to receive the epidural? Knee chest position with legs flexed and back arched. Modified lateral recumbent position with legs flexed and back arched. Semi-fowlers with back facing toward the anesthesiologist. Sit on the side of the bed with back straight and legs dangling.

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. Knee chest position is lying face down with the knees flexed and the buttocks up. It would be difficult for the HCP to insert the epidural catheter in this position. It might also decrease perfusion to the fetus. Semi-fowlers is supine in elevated in a 45 degree angle. It would be impossible to insert the epidural catheter in this position. Back straight would not expose the epidural space. This position would work if the back were arched, but it is not going to maintain optimal perfusion to the fetus.

Question 28 of 30 Which room and nursing staff assignments should be made for the client? Move the client to the mother/baby unit and assign a nurse with two other mother/baby couplets to care for her. Keep the client in recovery with a nurse who is also caring for four other recovering mothers. Move the client to a quiet room close to the nursing station in Labor and Delivery, and assign one nurse to care for her. Move the client to the Intensive Care unit (ICU) where a nurse with one other client can care for her.

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. This nurse/mother/baby couplet ratio is too high for the hourly assessment needed when a client remains on magnesium sulfate. The care ratio is too high. In addition, a client with preeclampsia has an irritated CNS, so a room with other clients (and usually family members) is inappropriate due to the risk of overstimulation. While ICU is often needed for clients with preeclampsia, particularly those who seize and/or require hemodynamic monitoring, the client is stable at present and does not require a transfer to the ICU.

Question 1 of 30 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? (Select all that apply. One, some, or all options may be correct.) Select all that apply Nulliparity. Familial history. History of pounding headache. Preexisting medical or genetic condition. Advanced maternal age.

Nulliparity. Familial history. Preexisting medical or genetic condition. Advanced maternal age. First pregnancy places a client at higher risk for preeclampsia than multiparity with the same partner. The client is older than 40 years of age and has a sister with a history of toxemia, which is an old term for preeclampsia that some clients may still use. Reasons for preeclampsia are unknown, but research shows that preexisting medical conditions and genetic conditions put the client at higher risk for preeclampsia. Age over 40 puts the client at increased risk of developing preeclampsia. A pounding headache is a symptom, not a risk factor.

Question 2 of 30 To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain? Pattern and number of prenatal visits. Prenatal blood pressure readings. Prepregnancy weight. Client's Rh factor.

Prenatal blood pressure readings. The client's blood pressure (BP) (138/88) is below the guideline that indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of 140/90 taken on two occasions 6 hours apart. However, the client's reading is significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal levels, particularly in combination with proteinuria, blurry vision, epigastric pain and hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the same during the first trimester. Both systolic and diastolic then decrease gradually up to 20-weeks' gestation. At 20 weeks' gestation, the blood pressure begins to gradually increase and return to 1st trimester levels at term. It is important to have early and consistent prenatal care, but this information will not help in the assessment of this client's condition. The nurse should compare today's weight to the client's most recently obtained previous weight, not to the prepregnancy weight. A weight gain of more than 2 pounds per week is indicative of mild preeclampsia. While the Rh factor of the mother is important in determining the need for prophylactic Rh immune globulin (RhoGAM) at 28 weeks and after birth, it is not the most important information at this time. All Rh negative women with negative indirect Coomb's tests are given RhoGam prophylactically at 28 weeks and then evaluated immediately after birth to determine if another dose of RhoGam is needed.

Question 19 of 30 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 anxiety caused by labor contractions is affecting the drug's efficacy. The HCP increased the dosage to achieve the level that prevents seizures. The oxytocin is having an adverse interaction with the magnesium sulfate. The HCP increased the level because your blood pressure keeps going up.

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. Anxiety can increase BP, but it does not affect the magnesium level. Oxytocin does not affect magnesium levels. This is not a nursing judgment. Antihypertensive drugs do not potentiate the effects of magnesium sulfate. However, if the BP continues to rise, the nurse should report it to the HCP, who may prescribe an antihypertensive.

Question 20 of 30 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? Cord compression is occurring due to oxytocin making the contractions stronger. The fetus' head is descending further into the pelvis and this causes the heart rate to decrease. The fetus has the same magnesium level as the mother's, causing the fetus to be sedated. The mother's hypertension has caused an acute stress incident in the fetus.

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. Although the increased contractions can cause cord compression in some fetuses, this is not a cause of decreased variability. Oxytocin itself does not cause the decreased variability. The head coming into the pelvis (at 0 station) would cause early decelerations, which are normal, but it is not related to a decrease in variability. While a mother's hypertension may decrease placental perfusion, the client arrived at the hospital with an elevated BP. Because the baby had moderate variability upon admission, it is unlikely the change in BP is the best explanation for the change.

Section 6 Nursing Process: Planning 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 solution Total fluid volume: 150 mL/hour Insert Foley catheter with urimeter attachment for hourly I&O Bed rest Vital signs & DTRs hourly after stabilized on magnesium sulfate Continuous uterine and fetal monitoring Calcium gluconate at bedside Begin oxytocin induction per protocol.

The primary line (nonadditive, or maintenance line) on the left side of the pole contains no medication. The secondary line with the orange "medication added" label contains oxytocin. The secondary oxytocin line is regulated by the infusion pump and is inserted into the lowest port in the primary fluid line. An external fetal monitor is used to assess the fetal response to oxytocin-stimulated contractions. The woman lies on her side to promote uterine blood flow.

Question 26 of 30 What should the nurse tell the client about pushing effectively? When the urge to push is felt, more of the epidural analgesic should be injected and the nurse will tell the client when and how to push each time there is a contraction. When the nurse palpates a contraction's beginning, take three shallow breaths and hold the breath for as long as possible while bearing down without allowing air to escape. 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. When the contraction begins on the fetal monitor, take a deep breath and hold it while bearing down for 10 seconds. Then take a quick breath and repeat the pushing pattern until the contraction ends on the monitor.

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. An epidural often reduces or blocks the urge to bear down. Analgesic doses are often adjusted to the lowest level possible to keep the client comfortable while maintaining the urge to push. This practice is not physiologically appropriate and has the potential to harm the fetus. The closed-glottis (prolonged breath-holding while pushing) technique 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. Although this technique is commonly seen in practice, it has the potential to harm the fetus. The closed-glottis (prolonged breath-holding while pushing) technique 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.