ATI Real Life 3.0 RN Preeclampsia

Nurse Morgan is preparing to teach Ms. Klein about delivery by C-section. Which of the following should Morgan Include in the teaching? (select all that apply)

1. Monitoring of the fetal HR will continue in preoperative teaching 2. you will receive antiemetic meds 3. you will receive pain med following the procedure

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.)

0.25

Nurse Morgan prepares to call Dr. Hunt and give report. Which of the following is the most important clinical data for Morgan to include in the SBAR report?

Elevated BP Greatest risk to client & her fetus is impaired tissue perfusion to the placenta & vital organs secondary to arteriolar vasospasm

Nurse Morgan completes an admission assessment for Ms. Klein. Based on the assessment, which of the following is the priority nursing intervention at this time?

initiate seizure precautions Greatest risk to client & fetus is injury from seizures & resulting hypoxemia.

Nurse Morgan is administering IV magnesium sulfate to Ms. Klein. Which of the following manifestations indicates Ms. Klein is experiencing magnesium toxicity?

respiration's 11/min RR of <12 min is indication of Mg toxicity

Nurse Morgan is preparing to administer magnesium sulfate IV at 2 g/hr. Available is magnesium sulfate 40 g/1,000 mL LR. Morgan should set the IV pump to deliver how many mL/hr? (round the answer to the nearest whole number)

50 mL/hr

Nurse Morgan reviews the lab test results for Ms. Klein. Which of the following findings confirms a diagnosis of severe preeclampsia?

Aspartate aminotransferase (AST) 75 units/ L

Nurse Alex is reviewing the EMRs in preparation to trader 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).

S: Ms. Kline is a 25 year old female that is 27 weeks gestation. She is G1, P0 she came into the ED this morning. B: Ms. Kline reports sudden wt gain and a new onset of N/V, also with blurred vision and headache. Says she had breakfast earlier this morning but states she vomitied soon after eating. A: VS- BP 162/88, HR 92, RR 22, Temp 37, O2 97%, urine protein 1+, deep tendon reflexes 3+, reports sharp right upper quadrant pain, N/V and blurred vision with a headache 8/10. R: transfer to Maternal newborn unit ----Same below: S: Ms. Kline is a 25 year old female that is 27 weeks gestation. She is G1, P0 she came into the ED this morning. B: Ms. Kline reports sudden wt gain & a new onset of N/V, also with blurred vision & H/A. States having breakfast earlier this morning but states she vomited after eating. A: VS- BP 162/88, HR 92, RR 22, T: 98.1, O2: 97%, urine protein 1+, deep tendon reflexes 3+, reports sharp RUQ pain, N/V & blurred vision with a H/A rated at 8/10. R: transfer to Maternal newborn unit

Nurse Morgan is reviewing Ms. Klein's lab test result. Which of the following findings should Morgan discuss with Ms. Klein regarding her worsening condition?

increased proteinuria

Nurse Morgan is reviewing prescription for Dr. Hunt, For which of the following manifestations should she plan to monitor following administration of hydralazine (Apresoline)?

Tachycardia and BP

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?

change Ms. Klein position change position to a lateral or knee-chest position to attempt to improve uteroplacental perfusion