Preeclampsia - HESI Case Study - NRSG376
Ashley's husband offers to sign the consent forms for her since she isn't feeling well right now. Which response by the nurse is correct? a) "That would be fine. Please read over the forms before you sign." b) "If Ashley does not feel like signing, we just wait until she feels better." c) "Ashley does not have to sign the informed consent." d) "Ashely should sign the consent forms herself since she is the once receiving the care."
"Ashley should sign the consent forms herself since she is the one receiving the care."
Ashely's sister is very concerned about the swelling (edema) 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 of water pills (diuretics) to help get rid of the excess fluid. Which response by the nurse is correct? a) "That is a very good idea. I will relay it to the healthcare provider when I call." b) "I'm sorry, but it is not the family's place to make suggestions about medical treatment." c) "Let me explain to you about the effect of diuretics on pregnancy." d) "Have you by any chance given your sister water pills that belong to someone else?"
"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.
Ashley's husband asks if some friends can visit now that the baby has been born. Which response by the nurse is most appropriate? a) "Absolutely not! Do you want to make her condition worse?" b) "You are a parent now. You have lots to learn while you're here." c) "Your wife is still at risk for complications, so visitors are limited to family members, and only for a short period of time." d) "Sure. I know they would love to see the new baby!"
"Your wife is still at risk for complications, so visitors are limited to family members, and only for a short period of time." This answer gives the client's spouse the facts about her condition (still at risk for complications). Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 593, 722), Elsevier.
While the nurse is awaiting the lab results to determine if Ashley has elevations in liver function, diminished kidney function, or altered coagulopathies, which question should the nurse ask Ashely? (Select all that apply). a) "Do you have any dizziness?" b) "Do you have blurry vision?" c) "Do you have abdominal pain?" d) "Do you have cramping in your calf when you flex your leg?" e) "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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. "Do you have blurry vision?" Retinal arterial spasms may cause blurring or double vision, photophobia, or scotoma (spots before the eyes). This is due to the cerebral edema. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. "Do you have abdominal pain?" An increase in microvascular fat deposits within the liver is postulated as one of the causes of abdominal pain. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. "Do you have cramping in your calf when you flex your leg?" This could indicate a deep vein thrombosis, not preeclampsia. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 730), Elsevier. "Do you have shortness of breath or chest discomfort?" 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier.
At 0600, Ashley is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen, swollen hands and face for 2 days, blurry vision, and epigastric pain described as bad heartburn. Her sister tells the registered nurse, "I felt like that when I had toxemia during my pregnancy." Admission assessment by the nurse reveals the following: today's weight 182 pounds, T 99.1-degrees F, P 76 beats/minute, R 22 breaths/minute, 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 Ashley's history, the RN is correct in concluding that Ashely is in jeopardy of developing a hypertensive disorder because of her age (42). Which other factors added to Ashely's risk of developing preeclampsia? (Select all that apply). a) Molar pregnancy and history of preeclampsia in previous pregnancy b) Familial history c) History of pounding headache, low socioeconomic status d) Preexisting medical or genetic condition, such as Factor V Leiden e) Nulliparity
-Familial history -Preexisting medical or genetic condition, such as Factor V Leiden -Nulliparity -Advanced maternal age
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. (Enter the numerical value only. If rounding is required, round to the whole number).
6 20 units = 20,000 mu (Calculate ml/hour, not drops/min)
The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced nurse? a) A 15-year-old gravida 1, para 0, with mild preeclampsia b) A 35-year-old gravida 3, para 2, with HELLP syndrome c) A 23-year-old gravida 2, para 0, with gestational diabetes d) A 16-year-old gravida 1, para 0, with preterm labor
A 35-year-old gravida 3, para 2, with HELLP syndrome
The day shift charge nurse is preparing to make client care assignments. 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. A 15-year-old gravida 1, para 0, with mild preeclampsia. While this client 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp.583- 594), Elsevier. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp.585- 586), Elsevier. A 23-year-old gravida 2, para 0, with gestational diabetes. While this client 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 626-630), Elsevier. A 16-year-old gravida 1, para 0, with preterm labor. While this client 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp.681-689), Elsevier.
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 Ashley: -Obtain permits for vaginal birth, cesarean birth, analgesia/anesthesia, and blood transfusion -Start on magnesium sulfate (4 g bolus over 20 minutes, then 1 g/hr per pump) per unit protocol -Following 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 What is the primary action of magnesium sulfate when given in preeclampsia? a) An antihypertensive b) A diuretic c) A CNS depressant d) A calcium channel blocker
A CNS depressant
The nurse asks Ashley 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. Ashley replies, "I think so," and then asks for a pen. Which action should the nurse take? a) Witness the signatures after Ashley and her husband have signed the consent form b) Call the HCP to explain all procedures again before asking Ashley to sign c) Explain all the procedures and risks, and then ask Ashley to sign d) Ask Ashley to explain what she understands about the procedures
Ask Ashley to explain what she understands about the procedures. Witness the signatures after the client and her spouse have signed the consent form. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 354), Elsevier. Call the HCP to explain all procedures again to the client before asking her to sign. This may need to be done eventually, but it is not the most appropriate choice at this point.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 354), Elsevier. Explain all the procedures and risks, and then ask the client to sign the consent form. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 354), Elsevier. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 354), Elsevier.
If magnesium toxicity is suspected, which medication should the nurse prepare to administer? a) Vitamin K b) Calcium gluconate c) Polystyrene sulfonate (Kayexalate) d) Corticosteroid
Calcium gluconate Vitamin K. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 594), Elsevier. Corticosteroid. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 594), Elsevier. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 594), Elsevier. Polystyrene sulfonate. 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 Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 594), Elsevier.
The RN is aware that continued magnesium sulfate puts Ashley at risk for postpartum hemorrhage eve though oxytocin is infusing. The nurse is aware that continued magnesium sulfate puts Ashley at risk for postpartum hemorrhage even though oxytocin is infusing. The nurse recognizes that which medication is safest for Ashley if a second drug is needed to treat postpartum hemorrhage? a) Carboprost tromethamine b) Methylergonovine c) Ergonovine d) 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. Methylergonovine. An ergot derivative, this medication is contraindicated for the client with preeclampsia because it increases the blood pressure. Ergonovine. An ergot derivative, this medication is contraindicated for the client with preeclampsia because it increases the blood pressure. Leonurus. While this herbal preparation 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.
Normal pregnancy is a vasodilated state. Peripheral vascular resistance decreased by 25%. Diastolic BP drops 10 mmHg at mild pregnancy and returns to pre-pregnancy levels at term. There is a 50% rise in blood volume and cardiac output increases 30% and 50%. Increased renal flow results in increased glomerular filtration rate. In preeclampsia, the main pathology is poor organ perfusion as a result of arteriolar vasospasm and endothelial activation. There is an increase in peripheral resistance when the blood pressure rises. It is more than just hypertension. It is a systemic disorder. Function in the placenta, liver, brain, and kidneys can be depressed as much as 40% to 60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen. The edema of preeclampsia is generalized. This disease affects virtually all organ systems, and the mother and fetus suffer increasing risk as the disease progresses. 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, eclampsia, or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. A client may present to the labor unit anywhere along that continuum. Hepatic involvement can lead to periportal hemorrhagic necrosis in the liver, which causes right upper quadrant or epigastric pain. What is the pathophysiology responsible for Ashley's complaint of a pounding headache and the elevated DTRs? a) Cerebral edema b) Increased perfusion to the brain c) Severe anxiety d) Retinal arteriolar spasms
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/minute, and R 18 breaths/minute. 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; hematocrit, 42.5 g/dL; platelets, 120,000 mm^3; aspartate aminotransferase (AST), slightly elevated; alanine aminotransferase (ALT), normal for pregnancy; 0 burr cells on slide; clotting studies normal for pregnancy. The HCP diagnoses Ashely with preeclampsia rather than HELLP syndrome, a variant of severe preeclampsia. If Ashley had HELLP syndrome, which lab results would the nurse expect to see? a) Elevated hemoglobin and hematocrit without burr cells, elevated liver enzymes, and decreased creatinine clearance b) Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased creatinine clearance c) Elevated hemoglobin and hematocrit with burr cells, decreased liver enzymes, and creatinine clearance 120 mL/min d) Decreased hemoglobin and hematocrit without burr cells, decreased liver enzymes, and creatinine clearance 134 mL/min
Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased creatinine clearance.
Which technique should the nurse use when evaluating Ashley's blood pressure while Ashley is on bedrest? a) Have Ashely lie supine and take the blood pressure on the left arm b) Have Ashely lie in a lateral position and take the blood pressure on the dependent arm c) Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level d) Have Ashley stand briefly and take the blood pressure on the right arm
Have Ashely lie in a lateral position and take the blood pressure on the dependent arm Have the client lie supine and take the blood pressure on the left arm. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier. Have the client stand briefly and take the blood pressure on the right arm. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 584-589), Elsevier.
Ashley 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 Ashley and her husband 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 Ashely 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? a) Hyperreflexia and increased respirations b) Hyporeflexia and irregular respirations c) Hyporeflexia and decreased respirations d) Hyperreflexia and irregular respirations
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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 684), Elsevier.
For which complication is Ashley most at risk following the epidural with a local anesthetic, such as bupivacaine or ropivacaine? a) Respiratory depression b) Elevated temperature c) Hypotension d) Spinal headache
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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 349-350), Elsevier.
Ashley 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? a) Implement a prescribed fluid bolus to improve maternal blood volume b) Increase the oxytocin infusion rate to hasten the birth c) Elevate the head of the bed 90 degrees to improve cardiac output d) 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 358), Elsevier.
The nurse performs a nonstress test to evaluate fetal well-being. Ashely 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? a) It evaluates the heart rate of the fetus in response to its own movements b) It measures the oxygen levels of the fetus c) Accelerations of the fetal heart rate in response to uterine contractions d) 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 It measures the oxygen levels of the fetus. Low oxygen levels may alter a nonstress test, but it is not measured with this test.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 578), Elsevier. Accelerations of the fetal heart rate in response to uterine contractions. Accelerations that occur with contractions (periodic accelerations) are usually linked to breech presentations and are not the basis for the nonstress test.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 578), Elsevier. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 578), Elsevier. Late decelerations of the fetal heart rate in response to uterine contractions. Late decelerations in response to uterine contractions are the basis for the contraction stress test.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 578), Elsevier.
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.
Knee chest position with legs flexed and back arched. 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. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 349-350), Elsevier. Semi-fowlers with back facing toward the anesthesiologist. Semi-fowlers is supine in elevated in a 45 degree angle. It would be impossible to insert the epidural catheter in this position. Sit on the side of the bed with back straight and legs dangling. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 349-350), Elsevier.
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 Ashely's output is 30 mL/hour and spontaneous rupture of membranes (SROM) has occurred with clear amniotic fluid. The nurse recognizes what type of periodic fetal heart rate change that is occurring? a) Variable decelerations b) Early decelerations c) Transient bradycardia d) Late decelerations
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.
What information should be included in the client and family teaching of magnesium sulfate? a) Magnesium is excreted in the urine, so the nurse will closely monitor the urine output b) This medication will be given intramuscular c) Magnesium sulfate increases the risk of having seizures d) Magnesium sulfate may cause hyperreactivity
Magnesium is excreted in the urine, so the nurse will closely monitor the urine output This medication will be given intramuscular every four hours for 24 hours. Magnesium sulfate is rarely given intramuscular, it is difficult to manage the therapeutic range. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 592), Elsevier. Magnesium sulfate may cause hyperactivity, leg cramps, and difficulty sleeping. Magnesium sulfate causes sedation, not hyperactivity. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 592), Elsevier. 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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 592), Elsevier. Magnesium sulfate increases the risk of having seizures and we will need to watch her closely. Magnesium sulfate decreases the risk of having seizures. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 592), Elsevier.
Ashley remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released Ashley from the postanesthesia care unit. Which room and nursing staff assignments should be made for Ashley? a) Move Ashley to the mother/baby unit and assign an RN with two other mother/baby couplets to care for her b) Keep Ashley in recovery with an RN who is also caring for four other recovering mothers c) Move Ashley to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her d) Move Ashley to the Intensive Care Unit (ICU) where an RN with one other client can care for her
Move Ashley to a quiet room close to the nursing station in Labor and Delivery, and assign one RN 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? a) Pattern and number of prenatal visits b) Prenatal blood pressure readings c) Pre-preganncy weight d) Ashely'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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, p. 586), Elsevier.
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.
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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 370-380), Elsevier.
No further seizures occur, and at 1100 the nursing assessment reveals that Ashley 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. Ashley 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 Ashley be positioned to receive the epidural? a) Supine with feet in stirrups b) Seated on edge of bed, slightly bent forward with legs dangling c) Prone position d) Semi-fowlers
Seated on edge of bed, slightly bent forward with legs danlging.
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 anxiety caused by labor contractions is affecting the drug's efficacy. Anxiety can increase BP, but it does not affect the magnesium level.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 593-594), Elsevier. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 593-594), Elsevier. The oxytocin is having an adverse interaction with the magnesium sulfate. Oxytocin does not affect magnesium levels.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 593-594), Elsevier. The HCP increased the level because your blood pressure keeps going up. 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.Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 593-594), Elsevier.
When evaluating the fetal monitor strip, the notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change? a) Cord compression is occurring due to oxytocin crossing the placenta b) The fetus' head is descending further into the pelvis c) The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated d) The mother's hypertension has caused an acute stress incident in the fetus
The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat 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.
The 0900 assessment reveals the following: Ashley 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-degrees F, P 80 beats/minute, R 19 breaths/,om, 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. Ashely reports mild discomfort with contractions, but she does not want anything for pain at this time. Ashely's husband is at the bedside helping her use relaxation breathing through each contraction. Ashely is in the right lateral position with the head of the bed slightly elevated. Ashely asks why the magnesium sulfate was increased. What explanation should the nurse provide? a) The magnesium is being excreted through the kidneys b) The anxiety caused by labor contractions is affecting the drug's efficacy c) The HCP should have also ordered an antihypertensive d) The oxytocin is having an adverse interaction with the magnesium
The magnesium is being excreted through the kidneys
At 0930 Ashely's husband rings the call bell and yells, "Come quickly, Ashely is shaking all over!" The nurse determines that Ashley is experiencing an eclamptic seizure. Which nursing intervention takes priority? a) Observe fetal monitor for non-reassuring patterns of fetal heart rate b) Turn Ashley onto her side and place a pillow behind her to stabilize the position c) Make a note of the time and sequence of the eclamptic seizure d) Suction the mouth, or oropharynx, and then apply oxygen at 10 liters per minute by facemask.
Turn Ashley 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.
At 1130 Ashley complains of rectal pressure and an urge to push. She reports no scotoma and no epigastric pain. Her vital signs are T 98.4-degrees F, 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. Ashley's cervix is now 10 cm dilated, and the fetal head is at +3 station. The RN informs the HCP. Because Ashely is completely dilated and has the urge to push, the RN reviews the proper pushing technique with Ashley and her partner. What should the nurse tell Ashely? a) 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 b) 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 c) 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. d) When the urge to push is felt, more of the epidural analgesic should be injected and the RN will tell the client when and how to push each time there is a contraction
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. Olshansky, E., Perry, S., Lowdermilk, D., Cashion, M. C., Alden, K. (2019). Maternity and Women's Health Care, (12th Edition, pp. 398-404), Elsevier.
