Chapter 27, Hypertensive Disorders

Which nursing finding is appropriate to evaluate when a client in labor who is at 38 weeks of gestation is treated with nifedipine for hypertension?

Labor progress

Which initial nursing action is appropriate when caring for a client who has had an eclamptic seizure?

Administer oxygen.

Which signs in a pregnant preeclamptic client would indicate the invasion stage of the tonic-clonic seizures? Select all that apply.

Fixed eyes Twitching of facial muscles

The nurse is preparing to administer intravenous magnesium sulfate to a client with preeclampsia. Meanwhile, the student nurse positions the client in the supine position, monitors the fetal heart rate (FHR), checks for baseline variability, and monitors for the absence of late decelerations. Which action by the student nurse indicates the need for further teaching?

Placing the client in a supine position

A pregnant client with severe preeclampsia is being transported to a tertiary care center and needs to be administered a magnesium sulfate injection for seizure activity. Which actions would the nurse take when administering the drug? Select all that apply.

A local anesthetic is added to the solution. The Z-track technique is used to inject the drug. The injection site is massaged after the injection.

Which hypertensive disorders can occur during pregnancy? Select all that apply.

Chronic hypertension Preeclampsia-eclampsia Gestational hypertension

The nurse is preparing a diet plan for a pregnant client with preeclampsia. Which would the nurse include in the client's diet? Select all that apply.

Food with a low sodium content Food with a high zinc content Six to eight glasses of water per day

The nurse knows that which conditions during pregnancy are risk factors for a client to develop preeclampsia? Select all that apply.

Nulliparity Multiple gestation Diabetes Chronic hypertension

What would the nurse assess to detect the presence of a hypertensive disorder in a pregnant client? Select all that apply.

Proteinuria Epigastric Presence of edema Blood pressure (BP)

The primary health care provider requests that the nurse test for proteinuria in a pregnant client. Which preliminary examinations would the nurse perform before testing for proteinuria to get accurate results? Select all that apply.

Presence of blood in the urine Presence of bacteria in the urine Presence of amniotic fluid in the urine

The nurse is caring for a postpartum client with preeclampsia. Which statement would the nurse include in discharge teaching?

"Return to the hospital if you have epigastric pain."

The nurse is assessing a pregnant client with preeclampsia on bed rest. Which region of the body would the nurse assess for edema in a client with preeclampsia?

Sacral region

Which condition in a pregnant client with severe preeclampsia is an indication for administering magnesium sulfate?

Seizure activity

Which conditions would the nurse remain alert for in a pregnant client with preeclampsia? Select all that apply.

Seizures Scotoma Cerebral edema

The nurse is teaching a pregnant client how to recognize signs of preeclampsia and when to report to the primary health care provider. Which statements by the client indicate effective learning? Select all that apply.

"I should report if I experience blurred vision or headache." "I should report if I feel a decrease in the baby's movements." "I should sit and use my right arm to accurately measure my blood pressure."

A client with severe gestational hypertension is prescribed hydralazine. Which is the priority nursing intervention in this case?

Assess blood pressure frequently.

The nurse observes that intravenous administration of magnesium sulfate has resulted in magnesium toxicity in a pregnant client with preeclampsia. The nurse immediately discontinues the infusion and reports to the primary health care provider. For which drug should the nurse obtain a prescription from the primary health care provider?

Calcium gluconate

The nurse caring for a 37-week-gestation client with gestational hypertension determines that the client has very elevated blood pressure. Which is the best intervention to prevent complications in the client?

Prepare the client for induction of labor.

The primary health care provider prescribes magnesium sulfate for a pregnant client who is being transported to the tertiary care center. Which actions would the nurse follow according to the protocol? Select all that apply.

Mix the drug with a local anesthetic agent. Administer 5 g to each buttock as a loading dose. Administer 5 g as a maintenance dose alternately to each buttock.

Which condition can be predicted in a pregnant client if uterine artery Doppler measurements in the second trimester of pregnancy are abnormal?

Preeclampsia

Which statement is accurate regarding preeclampsia and eclampsia?

Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain.

Which are the manifestations of HELLP syndrome? Select all that apply.

Hemolysis Low platelet count Elevated liver enzymes

A pregnant client has a systolic blood pressure greater than 160 mm Hg. Based on this finding, which action would the nurse take for this client?

Obtain a prescription for antihypertensive medications.

Which actions would the nurse take when a pregnant client has convulsions? Select all that apply.

Obtain a prescription for magnesium sulfate. Assess the client's airway, breathing, and pulse. Lower the bed and turn the client onto one side. Raise the side rails of the bed and pads with pillows.

The nurse is monitoring a client's deep tendon reflexes (DTRs) while receiving magnesium sulfate therapy for treatment of preeclampsia. Which assessment finding would indicate a cause for concern?

Positive clonus response elicited unilaterally

An 8-month-pregnant client presents with preeclampsia. Which clinical findings in the client indicate that the disease has progressed to HELLP syndrome? Select all that apply.

Hepatic dysfunction Elevated liver enzymes Low platelet count

Which instruction would the nurse provide to a pregnant client with mild preeclampsia?

"Fetal movement counts need to be evaluated daily."

A client is prescribed a 4-g loading dose of magnesium sulfate to be infused over 20 minutes. The nurse has available magnesium sulfate 40 g in 500 mL of normal saline. How many mL/hr will the nurse set the infusion pump to deliver the loading dose? __________ mL/hr

x = 150 mL/hr

Which is a priority nursing action when a pregnant client with severe gestational hypertension is admitted to the health care facility?

Administer the prescribed magnesium sulfate.

A client at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse would suspect the onset of which client condition?

Abruptio placentae

Which is the priority nursing action after administering magnesium sulfate to a pregnant client?

Assess the serum magnesium level.

The nurse is caring for a pregnant client at 30 weeks of gestation in preterm labor. Which medication would be administered to the client to enhance fetal lung maturation?

Betamethasone

The nurse is caring for a client with preeclampsia who gave birth by cesarean delivery. The primary health care provider prescribes a nonsteroidal antiinflammatory drug (NSAID) to the client for pain. Which parameter would the nurse closely monitor in this client?

Blood pressure

The nurse observes that eclampsia has developed in a pregnant client after starting magnesium sulfate therapy. Which action would the nurse take?

Continue to administer magnesium sulfate per protocol.

A pregnant client with eclampsia has developed convulsions. The nurse immediately elevates the head of the bed to prevent aspiration and turns the client onto her side. The nurse then assesses the status of the client's airway, breathing, and pulse. The nurse suctions secretions from the glottis to clear the airway, inserts an oral airway tube, and administers oxygen at 10 L/min through a face mask. Finally, the nurse administers intravenous (IV) magnesium sulfate as prescribed. Which nursing intervention indicates the need for further teaching?

Elevating the head of the bed to prevent aspiration

The nurse caring for a pregnant client knows that which situation is the most common medical complication of pregnancy?

Hypertension

A woman with severe preeclampsia is being treated with an intravenous infusion of magnesium sulfate. When is this treatment considered successful?

If seizures do not occur

The nurse knows that which factor(s) is associated with HELLP syndrome?

It is characterized by hemolysis, elevated liver enzymes, and low platelet count.

Which antihypertensive medications would cause a pregnant woman to have a positive Coombs test result?

Methyldopa

The nurse is caring for a postpartum client receiving intravenous magnesium sulfate. Which other medications would the nurse check for in the treatment regimen to ensure the client's safety? Select all that apply.

Narcotics Calcium channel blockers Central nervous system (CNS) depressants

The nurse observes that a pregnant client with gestational hypertension who is on magnesium sulfate therapy is prescribed nifedipine. Which action would the nurse take?

Obtain a prescription for a change of drug.

Which interventions would the nurse include in the plan of care for a pregnant client with mild preeclampsia? Select all that apply.

Provide diversionary activities. Encourage intake of adequate fluids. Refer to the client to an Internet-based support group.

The nurse is caring for a preterm baby in the neonatal intensive care unit (NICU) who was born to a client with preeclampsia. The family is anxious about the baby. Which nursing interventions would help relieve anxiety in the family? Select all that apply.

Providing the family with photographs of the baby Allowing the partner/spouse to visit the neonatal intensive care unit (NICU) Informing family members about the baby's status

Which system is a nursing priority after evaluating the information from the electronic health record for a client admitted with newly diagnosed preeclampsia?

Renal

How would the nurse classify a client who is at 18 weeks of gestation and has a blood pressure of 140/98 and a past medical history of treatment for hypertension?

Superimposed preeclampsia

The nurse is caring for a pregnant client with chronic hypertension. Which additional complication is most likely to be seen in this client?

Superimposed preeclampsia

A pregnant client has a sudden onset of seizures during the third trimester of pregnancy. After reviewing the client's medical history, the nurse determines the client had hypertension and proteinuria since 21 weeks of gestation. Which client condition would the nurse infer from these findings?

The client has eclampsia.

The nurse is caring for a client who gave birth vaginally 2 days ago and notes that the client has a blood pressure of 160/105 mm Hg. The nurse would monitor the client for which complications to ensure her safety? Select all that apply.

Renal failure Pulmonary edema

The nurse is caring for a client with severe preeclampsia who is on an intravenous infusion of magnesium sulfate. Which assessment parameter indicates that the treatment is a success?

Seizures do not occur.

Which intervention would help prevent the risk of pulmonary edema in a pregnant client with severe preeclampsia?

Restrict total intravenous and oral fluids to 125 mL/hr.

A client with severe preeclampsia is receiving a magnesium sulfate infusion. Which assessment finding would be most concerning to the nurse?

A respiratory rate of 10 breaths/min

Which finding in a urine specimen of a pregnant client indicates that the client has proteinuria?

Value greater than 300 mg/24 hours

The nurse finds diuresis, weight loss, and muscle atrophy in a pregnant client with mild preeclampsia. Which client condition would the nurse conclude from these findings?

The client was on prolonged bed rest.

A client with gestational hypertension is prescribed labetalol hydrochloride therapy, which is continued postpartum. Which instruction would the nurse provide the client about breastfeeding?

"You may breastfeed the infant if you desire."

A client with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the client and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the primary health care provider and anticipates a prescription for which medication?

Hydralazine

The nurse is caring for a pregnant client with preeclampsia. The client reports severe and persistent epigastric pain. In reviewing the client's blood test, which result may indicate worsening liver function?

Increased liver transaminase levels

The nurse is caring for a hypertensive pregnant client who is on magnesium sulfate therapy. The nurse finds that the client has drowsiness, slurred speech, and depressed respiration. Which medication would the nurse anticipate the primary health care provider will prescribe to reverse these findings?

Intravenous calcium gluconate

A pregnant client is a 38-year-old primigravida, with a body mass index of 32. Which medication would help in reducing the risk of preeclampsia in this client?

Low-dose aspirin

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) magnesium sulfate infusion. In assessing the client every 20 minutes, which maternal findings would require immediate intervention by the nurse?

Respiratory rate of 9 breaths/min