Practice NCLEX Q's: Preeclampsia, Eclampsia,

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.) Proteinuria 2.)Hypertension 3.)Low-grade fever 4.)Generalized edema 5).Increased pulse rate 6.)Increased respiratory rate

1.) Proteinuria 2.)Hypertension Rationale:The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur, but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1.) Restrict food and fluids. 2.) Reduce external stimuli. 3.) Monitor blood glucose levels. 4.) Maintain the client in a supine position.

2.) Reduce external stimuli. Rationale:The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs? 1.)Urine test is negative for protein. 2.)Fetal movements are more than 4 per hour. 3.)Weight increases by more than 1 pound in a week. 4.)The blood pressure reading ranges between 122/80 mm Hg and 130/82 mm Hg.

3.)Weight increases by more than 1 pound in a week. Rationale:The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (3 or fewer movements per hour) may indicate fetal compromise and should be reported.

A 19-year-old gravida 1, para 0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? Select all that apply. 1.) Check deep tendon reflexes. 2.) Observe for vaginal bleeding. 3.) Check the respiratory rate. 4.) Note the urine output. 5.) Monitor for calf pain.

1,3,4 1.) Check deep tendon reflexes. 3.) Check the respiratory rate. 4.) Note the urine output. Rationale:Magnesium sulfate toxicity can cause fatal cardiovascular events or respiratory depression or arrest, so monitoring of respiratory rate is of utmost importance. The drug is excreted by the kidneys, and therefore monitoring for adequate urine output is essential. Deep tendon reflexes disappear when serum magnesium is reaching a toxic level. Vaginal bleeding is not associated with magnesium sulfate use. Calf pain can be a sign of a deep vein thrombosis but is not associated with magnesium sulfate therapy.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? 1.) A private room across from the elevator 2.) A semiprivate room across from the nurses' station 3.) A private room 2 doors away from the nurses' station 4.) A semiprivate room with another client who enjoys watching television

3.) A private room 2 doors away from the nurses' station Rationale:A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room 2 doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator and a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia.

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1.) Tongue blade 2.) Percussion hammer 3.)Potassium chloride injection 4.)Calcium gluconate injection

4.)Calcium gluconate injection Rationale:Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest priority item. Potassium chloride is not related to the administration of magnesium sulfate.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1.)Enlargement of the breasts 2.) Complaints of feeling hot when the room is cool 3.)Periods of fetal movement followed by quiet periods 4.)Evidence of bleeding, such as in the gums, petechiae, and purpura

4.)Evidence of bleeding, such as in the gums, petechiae, and purpura Rationale:Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? 1.) Assess for signs and symptoms of labor. 2.)Assess the client's temperature every 2 hours. 3.)Schedule a daily ultrasound to assess fetal movement. 4.)Schedule a nonstress test every 4 hours to assess fetal well-being.

1.) Assess for signs and symptoms of labor. Rationale:As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1.) Monitor for fetal movement. 2.) Monitor the maternal blood glucose. 3.) Instruct the client to maintain complete bed rest. 4.) Instruct the client to restrict dietary sodium and any food items that contain sodium.

1.) Monitor for fetal movement. Rationale:A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1.) Administer oxygen by face mask. 2.) Clear and maintain an open airway. 3.)Administer magnesium sulfate intravenously. 4.)Assess the blood pressure and fetal heart rate.

2.) Clear and maintain an open airway. Rationale:The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? 1.) Urinary output has increased. 2.) Dependent edema has resolved. 3.)Blood pressure reading is at the prenatal baseline. 4.) The client complains of a headache and blurred vision.

4.) The client complains of a headache and blurred vision. Rationale:If the client complains of a headache and blurred vision, the HCP should be notified, because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1.)Keep the room semi-dark. 2.)Initiate seizure precautions. 3.)Pad the side rails of the bed. 4.)Avoid environmental stimulation. 5.)Allow out-of-bed activity as tolerated.

1,2,3,4 1.)Keep the room semi-dark. 2.)Initiate seizure precautions. 3.)Pad the side rails of the bed. 4.)Avoid environmental stimulation. Rationale:Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. 1.)Assess blood pressure. 2.)Check the urine for protein. 3.)Assess deep tendon reflexes. 4.)Discuss the need for hospitalization. 5.)Teach the importance of keeping track of a daily weight.

1,2,3,5 1.)Assess blood pressure. 2.)Check the urine for protein. 3.)Assess deep tendon reflexes. 5.)Teach the importance of keeping track of a daily weight. Rationale:With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition.