Preeclampsia Simulation:Real Life RN Maternal Newborn 2.0
Scenario Nurse Morgan is preparing Ms. Klein for surgery. Question Nurse Morgan is preparing to teach Ms. Klein about delivery by cesarean section. Which of the following should Morgan include in the teaching? (Select all that apply.)
Selected Option "You will receive antiemetic medications." "Monitoring of the fetal heart will continue." "You will receive pain medication following the procedure." Rationale The nurse should include administration of pain and antiemetic medications, and continued fetal heart rate monitoring in the preoperative teaching. The client will provide informed consent, not her spouse, and the anesthesiologist should discuss the options for anesthesia as part of the informed consent.
Scenario Nurse Morgan calculates the dosage of hydralazine (Apresoline). Question Nurse Morgan is preparing to administer hydralazine (Apresoline) 5 mg IV bolus. Available is hydralazine 20 mg/mL. How many mL should Morgan administer? (Round the answer to the nearest hundredth.)
Selected Option 0.25 Rationale STEP 1: What is the unit of measurement to calculate? mL STEP 2: What is the dose needed? Dose needed = Desired. 5 mg STEP 3: What is the dose available? Dose available = Have. 20 mg STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the Quantity of the dose available? 1 mL STEP 6: Set up the equation and solve for X. Have = Desired Quantity X 20 mg = 5 mg 1 mL X mL X = 0.25 STEP 7: Round, if necessary. STEP 8: Reassess to determine the amount to administer makes sense. If there are 20 mg/mL and the amount prescribed is 5 mg, it makes sense to administer 0.25 mL. The nurse should administer hydralazine 0.25 mL IV.
Scenario Nurse Morgan calculates the rate of infusion of magnesium sulfate. Question Nurse Morgan is preparing to administer magnesium sulfate IV at 2 g/ hr. Available is magnesium sulfate 40 g/1,000 mL lactated Ringer's. Morgan should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
Selected Option 50 mL/hr Rationale STEP 1: What is the unit of measurement to calculate? mL/hr STEP 2: What is the volume needed? 2 g STEP 3: What is the total infusion time? 1 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up the equation and solve for X. Have = Desired Quantity X 2 g = 40 g X mL 1,000 mL X = 50 STEP 6: Round, if necessary. STEP 7: Reassess to determine the amount to administer makes sense. If the amount prescribed is 2 g/hr and available is 40 g/1,000 mL, it makes sense to administer 50 mL/hr. The nurse should set the IV pump to deliver magnesium sulfate at 50 mL/hr.
Scenario Nurse Morgan reviews laboratory test results for Ms. Klein. Question Nurse Morgan reviews the laboratory test results for Ms. Klein. Which of the following findings confirms a diagnosis of severe preeclampsia?
Selected Option Aspartate aminotransferase (AST) 75 units/L Rationale This liver enzyme is significantly elevated and is consistent with a diagnosis of severe preeclampsia.
Scenario Nurse Morgan recognizes a nonreassuring fetal heart rate. Question Nurse Morgan recognizes Ms. Klein is experiencing variable decelerations of the fetal heart rate. Which of the following nursing interventions should Morgan take at this time?
Selected Option Change Ms. Klein's position Rationale The nurse should change the client's position to a lateral or knee-chest position to attempt to improve uteroplacental perfusion.
Scenario Nurse Morgan prepares to call Dr. Hunt and give a report. Question Nurse Morgan prepares to call Dr. Hunt and give a report. Which of the following is the most important clinical data for Morgan to include in the SBAR report?
Selected Option Elevated blood pressure Rationale The elevated blood pressure is the priority clinical finding to include in the SBAR report. The greatest risk to the client and her fetus is impaired tissue perfusion to the placenta and vital organs secondary to arteriolar vasospasm.
Scenario Nurse Morgan is reviewing Ms. Klein's laboratory test results. Question Nurse Morgan is reviewing Ms. Klein's laboratory test results. Which of the following findings should Morgan discuss with Ms. Klein regarding her worsening condition?
Selected Option Increased proteinuria Rationale Proteinuria increases with the worsening of preeclampsia.
Scenario Nurse Morgan completes the admission assessment and selects the appropriate nursing interventions. Question Nurse Morgan completes an admission assessment for Ms. Klein. Based on the assessment, which of the following is the priority nursing intervention at this time?
Selected Option Initiate seizure precautions. Rationale The greatest risk to the client and fetus is injury from seizures and resulting hypoxemia. The priority intervention is to initiate seizure precautions.
Scenario Nurse Morgan assesses Ms. Klein during the administration of IV magnesium sulfate. Question Nurse Morgan is administering IV magnesium sulfate to Ms. Klein. Which of the following manifestations indicates Ms. Klein is experiencing magnesium toxicity?
Selected Option Respirations 11/min Rationale A respiratory rate of less than 12/min is an indication of magnesium toxicity. The nurse should report this manifestation to the provider.
Scenario Nurse Alex performed a focused assessment and is preparing to transfer Ms. Kline to the maternal newborn unit. Question Nurse Alex is reviewing the EMRs in preparation to transfer Ms. Kline to the maternal newborn unit. Use the SBAR format to prepare a transfer report. (Type your response in the text box below and then click the submit button.
Selected Option S- Situation- 25y/o F, G1 P0 @ 27 weeks gestation. Came to the ED @ 08:00 B- Background Reports sudden wt gain, new onset of N/V w/ blurred vision & HA. Says she had breakfast earlier this morning but vomited soon after eating A-Assessment VS= T37.0 P92 R22 BP 162/88 O2 sats 97% Urine protein +1 DTR's +3 Reports R upper quadrant px, n/v & blurred vision w/ HA R=Recommendations xfer to M/N unit Rationale SBAR: S = Situation: 25 year-old female, gravida 1 para 0, at 27 weeks gestation. Came to the ED this morning at 0800. B = Background: Reports sudden weight gain, and a new onset of nausea & vomiting, also blurred vision and headache. Says she had breakfast earlier this morning but that she vomited soon after eating. A = Assessment: Vital Signs: T 37.0, P 92, R 22, BP 162/88, O2 sat 97%, urine protein 1 +, deep tendon reflexes 3+, reports right upper quadrant pain, nausea and vomiting and blurred vision with a headache. R = Recommendation: transfer to maternal newborn unit.
Scenario Nurse Morgan reviews prescriptions from Dr. Hunt. Question Nurse Morgan is reviewing prescriptions from Dr. Hunt. For which of the following manifestations should she plan to monitor following administration of hydralazine (Apresoline)?
Selected Option Tachycardia Rationale Following administration of hydralazine, the nurse should monitor for alterations in blood pressure and tachycardia.