Complications of Pregnancy NCLEX- preeclampsia

What is the value of the main line fluid rate for your client, whose total fluid intake is ordered at 150 mL/hr and who is also being given magnesium sulfate at 1 g/hr (1 g = 25 mL/hr) IV piggyback and pitocin at 15 mU/min (l mU/min = 1 mL/hr) IV piggyback.

110 ~ The rate of infusion of magnesium sulfate (25 mL/hr) and pitocin (15 mL/hr) equals 40 mL/hr. Subtracting the 40 mL from the total ordered of 150 mL leaves 110 mL of main line fluid to be infused per hour.

A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome? a. Platelet count of 50,000/mL b. Liver enzyme levels within normal range c. Negative for edema d. No evidence of nausea or vomiting

A ~ HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet count. A platelet count of 50,000/mL indicates thrombocytopenia.

The emergency room charge nurse calls the labor and birth charge nurse and reports the ambulance is en route with a seizing pregnant patient at 36 weeks gestation. What medication will the charge nurse most likely direct the staff nurse to prepare to administer immediately on the patients arrival to the labor and birth unit? a. Magnesium sulfate (magnesium) b. Hydralazine (Apresoline) c. Carbamazepine (Tegretol) d. Terbutaline (Brethine)

A ~ Magnesium sulfate is the drug most often used for preeclamptic and eclamptic patients. It is a CNS depressant. Apresoline is administered for hypertension and is often given to pregnant clients with severe preeclampsia. Tegretol is administered for seizure activity in nonpregnant patients. Brethine is a smooth muscle relaxant administered for preterm labor.

What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks gestation presenting with abdominal pain and bleeding? a. Treated 1 year ago for pelvic inflammatory disease (PID) b. Oral contraception for last 3 years c. Urinary frequency for 1 week d. Irregular cycles for 1 year prior to conception

A ~ PID causes fallopian tube damage. Blockage of the tube prevents movement of the fertilized ovum, resulting in implantation in the tube. Oral contraception for the last 3 years, urinary frequency for 1 week, and irregular cycles for 1 year prior to conception have no effect on the development of ectopic pregnancy.

Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome? a. Abdominal palpation b. Venous sample of blood c. Checking deep tendon reflexes d. Auscultation of the heart and lungs

A ~ Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia.

The clinic nurse is reviewing home care dietary instructions for the patient diagnosed with mild preeclampsia at 34 weeks gestation. The nurse determines that the client requires additional information when she makes which statement? a. I will limit my salt intake to 2 grams per day. b. I will drink no less than 2500 mL of fluid per day. c. I will make sure I eat 4 sources of protein per day. d. My overall intake of calories per day should be around 2500.

A ~ The diet should have ample protein, no less than 6 ounces/day, and approximately 2500 calories during the second half of pregnancy. A regular diet without salt or fluid restriction is usually prescribed. Adequate amounts of protein are essential, especially because there is pathologic protein loss with preeclampsia.

The nurse who suspects that a client has early signs of ectopic pregnancy should be observing her for which symptoms? (SATA) a. Pelvic pain b. Missed period c. Abdominal pain d. Unanticipated heavy bleeding e. Vaginal spotting or light bleeding

A, B, C, E ~ A missed period or spotting can easily be mistaken by the client as early signs of pregnancy. More subtle signs depend on exactly where the implantation occurs. The nurse must be thorough in her assessment because pain is not a normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intraabdominal hemorrhage. This may progress to hypovolemic shock with minimal or even no external bleeding. In about 50% of women, shoulder and neck pain occurs because of irritation of the diaphragm from the hemorrhage.

Which assessment finding indicates an adverse response to magnesium sulfate? a. Urine output of 30 mL/hr b. Respiratory rate of 11 breaths/min c. Hypoactive patellar reflex d. Blood pressure reading of 110/80 mm Hg

B ~ A respiratory rate less than 12 breaths/min indicates magnesium toxicity and requires immediate intervention. A urine output of 30 mL/hr is normal urinary output; a hypoactive patellar reflex and blood pressure reading of 110/80 mm Hg are normal findings in the client receiving magnesium sulfate.

Which intervention would be the most effective if your client who is on magnesium sulfate has a respiratory rate of 10 breaths/min? a. Give oxygen by mask at 8-10 L/min. b. Administer calcium gluconate via IV pyelogram (IVP). c. Arouse client with tactile stimulation. d. Continually assess pulse oximeter levels.

B ~ A respiratory rate of less than 12 breaths/min in a client receiving magnesium sulfate is a sign of magnesium toxicity, which must be immediately reversed. Calcium gluconate opposes the effects of magnesium at the neuromuscular junction and is an antidote for magnesium toxicity. Oxygen by mask at 8 to 10 L/min, arousing a client with tactile stimulation, and continually assessing pulse oximeter levels will not be effective until the magnesium toxicity has been reversed.

The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to: a. monitor uterine contractions. b. assess fetal heart rate and maternal vital signs. c. place clean disposable pads to collect any drainage. d. perform a venipuncture for hemoglobin and hematocrit levels.

B ~ Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and fetal well-being. The blood levels can be obtained later.

A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? a. Increase the clients IV fluids. b. Administer calcium gluconate. c. Vigorously stimulate the client. d. Instruct the client to take deep breaths.

B ~ Calcium gluconate reverses the effects of magnesium sulfate. Increasing the clients IV fluids will not reverse the effects of the medication. Stimulation will not increase the respirations. Deep breaths will not be successful in reversing the effects of the magnesium sulfate.

Which assessment finding suggests that your laboring client's blood magnesium level is too high? a. Hyperactive reflexes b. Absent reflexes c. Generalized seizure d. Urine output of 60 mL/hr

B ~ Magnesium acts as a central nervous system depressant by blocking neuromuscular transmission. Assessment of the deep tendon reflexes is an indication of the level of CNS depression. Absent reflexes indicates magnesium toxicity; hyperactive reflexes, generalized seizure, and urine output of 60 mL/hr are not symptoms of magnesium toxicity.

A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted? a. Obtain the patients weight. b. Take the patients vital signs. c. Start an IV with lactated Ringers at 75 mL/hr. d. Ask support persons to leave the birthing room.

B ~ The hallmark signs of preeclampsia are hypertension and proteinuria. These parameters must be evaluated first. Obtaining the patients weight may indicate excess fluid gain, but fluid retention does not occur in all cases of preeclampsia. An IV will be beneficial; however, assessment precedes implementation in this case to obtain baseline data. Promoting a nonstimulating environment can help decrease blood pressure; however, loss of support during this frightening time can increase anxiety in this initial assessment phase and actually increase the patient's blood pressure.

A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patients magnesium level is 7.6 mg/dL. What is the nurses priority action? a. Stop the infusion of magnesium. b. Assess the patients respiratory rate. c. Assess the patients deep tendon reflexes. d. Notify the health care provider of the magnesium level.

B ~ The therapeutic serum level for magnesium is 4 to 8 mg/dL although it is elevated in terms of normal lab values. Adverse reactions to magnesium sulfate usually occur if the serum level becomes too high. The most important is CNS depression, including depression of the respiratory center. Magnesium is excreted solely by the kidneys, and the reduced urine output that often occurs in preeclampsia allows magnesium to accumulate to toxic levels in the woman. Frequent assessment of serum magnesium levels, deep tendon reflexes, respiratory rate, and oxygen saturation can identify CNS depression before it progresses to respiratory depression or cardiac dysfunction. Monitoring urine output identifies oliguria that would allow magnesium to accumulate and reach excessive levels. Discontinue magnesium if the respiratory rate is below 12 breaths/min, a low pulse oximeter level (<95%) persists, or deep tendon reflexes are absent. Additional magnesium will make the condition worse.

Which is the only known cure for preeclampsia? a. Magnesium sulfate b. Delivery of the fetus c. Antihypertensive medications d. Administration of aspirin (ASA) every day of the pregnancy

B ~If the fetus is viable and near term, birth is the only known cure for preeclampsia. Magnesium sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (60 to 80 mg) have been administered to women at high risk for developing preeclampsia.

The nurse is monitoring a client with severe preeclampsia who is on IV magnesium sulfate. Which signs of magnesium toxicity should the nurse monitor for? (SATA) a. Cool, clammy skin b. Altered sensorium c. Pulse oximeter reading of 95% d. Respiratory rate of less than 12 breaths/min e. Absence of deep tendon reflexes

B, D, E ~ Signs of magnesium toxicity include the following: Respiratory rate of less than 12 breaths/min (hospitals may specify a rate < 14 breaths/min) Maternal pulse oximeter reading lower than 95% Absence of deep tendon reflexes Sweating, flushing Altered sensorium (confused, lethargic, slurred speech, drowsy, disoriented) Hypotension Serum magnesium value above the therapeutic range of 4 to 8 mg/dL Cold, clammy skin and a pulse oximeter reading of 95% would not be signs of toxicity.

A preeclamptic patient is receiving an IV infusion of magnesium sulfate. On assessment, the nurse notes that the patient's urinary output has been 20 mL/hr for the past 2 hours and her deep tendon reflexes are absent. The health care provider prescribes calcium gluconate, 1 g of a 10% solution. The standard rate of infusion is 1 mL/min. How many minutes will it take for the nurse to administer the prescribed calcium? a. 1 b. 5 c. 10 d. 15

C ~ A 10% solution contains 10 g in 100 mL. X minutes = 1 minute 100 mL 1 g = 10 minutes 1 mL 10 g

A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic. c. anticonvulsant. d. antihypertensive.

C ~ Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate.

A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? a. +1 b. +2 c. +3 d. +4

C ~ Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2 edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal cavity.

The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia? a. Edema b. Proteinuria c. Glucosuria d. Hypertension

C ~ Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant client is rapid weight gain & edema of the hands & face. Proteinuria usually develops later than the edema & hypertension. The first indication of preeclampsia is usually an increase in the maternal blood pressure.

Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication? a. Drowsiness b. Urinary output of 20 mL/hr c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/min

C ~ Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hr is not adequate output. A respiratory rate of 10 to 12 breaths/min is too slow and could be indicative of magnesium toxicity.

What should the nurse recognize as evidence that the client is recovering from preeclampsia? a. 1+ protein in urine b. 2+ pitting edema in lower extremities c. Urine output >100 mL/hr d. Deep tendon reflexes +2

C ~ Rapid reduction of the edema associated with preeclampsia results in urinary output of 4 to 6 L/day as interstitial fluids shift back to the circulatory system. 1+ protein in urine and 2+ pitting edema in lower extremities are signs of continuing preeclampsia. Deep tendon reflexes are not a reliable sign, especially if the client has been treated with magnesium.

The most appropriate nursing action for the client complaining of continuous headache 24 hours postpartum after a normal vaginal birth is to: a. encourage bed rest. b. administer analgesic. c. assess blood pressure. d. assess for pitting edema.

C ~ The first indication of preeclampsia is usually hypertension. Continuous headache indicates poor cerebral perfusion and may be a precursor of seizures; encouraging bed rest, administering an analgesic, and assessing for edema are not interventions to determine the source of the clients headache.

A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to: a. advise her to cut down on fast foods that are high in fat. b. caution her to avoid salty foods and to return in 2 weeks. c. assess weight gain, location of edema, and urine for protein. d. recommend she stay home from school for a few days to reduce stress.

C ~ The nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she needs further assessment to determine if pregnancy-induced hypertension is the problem.

A client with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting? a. Pregnancy-induced hypertension (PIH) b. Gestational hypertension c. Preeclampsia superimposed on chronic hypertension d. Undiagnosed chronic hypertension

D ~ Even though the client has no documented prenatal care or medical history, she does relate a family history that is positive for heart disease. Additionally, the clients blood pressure increased following birth and was treated in the hospital and resolved. Now the client appears at the 6-week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to suggest that the client was preeclamptic prior to the birth.

Which assessment finding indicates the development of preeclampsia in the antepartum client? a. Slight edema of feet and ankles. b. Increased urine output c. Blood pressure of 128/80 mm Hg d. Weight gain of 3 pounds in 1 week

D ~ Generalized edema often occurs with preeclampsia. Edema may first manifest as a rapid weight gain. Normal weight gain in the second and third trimesters is 1 pound per week; slight edema of feet and ankles, increased urine output, and blood pressure of 128/80 mm Hg are normal findings in pregnancy.

A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion.

D ~ Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety.