PREECLAMPSIA/ECLAMPSIA - LIPINCOTT BOOK

11. When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain? 1. Oxytocin infusion solution. 2. Disposable tongue blades. 3. Portable ultrasound machine. 4. Padding for the side ra

1. 4. The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority

10. A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say she has a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client: 1. "Take two acetaminophen (Tylenol) tablets. They aren't as likely to upset your stomach." 2. "I think the doctor should see you today. Can you come to the clinic this morning?" 3. "You need to lie down and rest. Have you tried placing a cool compress over your head?" 4. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"

10. 2. A client with preeclampsia and a continuous headache for 2 days should be seen by a health care provider immediately. Continuous headache, drowsiness, and mental confusion indicate poor cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Aspirin with codeine may temporarily relieve the client's headache. However, this delays immediate treatment, which is crucial. Additionally, pregnant women are advised not to take aspirin at this time because it may cause clotting problems in the neonate. Codeine generally is not prescribed.

12. The primary health care provider prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside? 1. Diazepam (Valium). 2. Hydralazine (Apresoline). 3. Calcium gluconate. 4. Phenytoin (Dilantin).

12. 3. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.

13. For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia? 1. Decreased deep tendon reflexes. 2. Cool skin temperature. 3. Rapid pulse rate. 4. Tingling in the toes.

13. 1. Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

14. A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time? Select all that apply. 1. Reassure the client that headaches are a normal part of pregnancy. 2. Assess the client for vision changes or epigastric pain. 3. Obtain a nonstress test. 4. Assess the client's reflexes and presence of clonus. 5. Determine if the client has a documented ultrasound for this pregnancy

14. 2,3,4. Headaches could be a sign of preeclampsia/eclampsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyper reflexes, and the presence of clonus. Her fetus should be assessed using a nonstress test. An ultrasound done in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia.

15. Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? 1. Decreased generalized edema within 8 hours. 2. Decreased urinary output during the first 24 hours. 3. Sedation and decreased reflex excitability within 48 hours. 4. Absence of any seizure activity during the first 48 hours.

15. 4. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

16. The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? Select all that apply. 1. T98(36.7),P72,R14. 2. Urinary output less than 30 mL/h. 3. Fetal heart rate with late decelerations. 4. BP of less than 140/90. 5. DTR 2+. 6. Magnesium level = 5.6 mg/dL (2.8 mmol/L).

16. 1,5,6. The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine liberated. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (RPM). Rates at 12 RPM or lower are associated with respiratory depression and are seen with magnesium toxicity. Renal compromise is identified with a urinary output of less than 30 mL/hour. A fetal heart rate that is maintained within the 112 to 160 range is desired without later or variable decelerations. Deep tendon reflexes should not be diminished or exaggerated. The therapeutic magnesium sulfate level of 5 to 8 mg/dL (2.5 to 4 mmol/L) is to be maintained.

18. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first? 1. Insert an airway to improve oxygenation. 2. Note the time when the seizure begins and ends. 3. Call for immediate assistance. 4. Turn the client to her left side.

18. 3. If a client begins to have a seizure, the first action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained.

19. After administering hydralazine (Apresoline) 5 mg intravenously as prescribed for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for: 1. Tachycardia. 2. Bradypnea. 3. Polyuria. 4. Dysphagia.

19. 1. One of the most common adverse effects of the drug hydralazine (Apresoline) is tachycardia. Therefore, the nurse should assess the client's heart rate and pulse. Hydralazine acts to lower blood pressure by peripheral dilation without interfering with placental circulation. Bradypnea and polyuria are usually not associated with hydralazine use. Dysphagia is not a typical adverse effect of hydralazine.

24. The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results? 1. Platelets 200,000 mm3 (200 × 109/L). 2. Lactate dehydrogenase (LDH) greater than 200 U/L (3.34 μkat/L). 3. Uric acid 3 mg/dL (178.4 μmol/L). 4. Aspartate aminotransferase (AST) 15 U/L (0.25 μkat/L).

2. The normal value of LDH in a nonpregnant person is 45 to 90 U/L (0.75 to 1.5 μkat/L). LDH elevations indicate tissue destruction that can occur with HELLP syndrome. This platelet range is in the normal range and remains unchanged during pregnancy. Uric acid in a nonpregnant woman is 2 to 6.6 mg/dL (119 to 393 μmol/L). AST normal range is 4 to 20 U/L (0.07 to 0.33 μkat/L).

20. A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following? 1. 1+. 2. 2+. 3. 3+. 4. 4+.

20. 4. These findings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements.

21. A 16-year-old unmarried primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's blood pressure is 164/110 mm Hg. Which of the following would alert the nurse that the client may be about to experience a seizure? 1. Decreased contraction intensity. 2. Decreased temperature. 3. Epigastric pain. 4. Hyporeflexia.

21. 3. Epigastric pain or acute right upper quadrant pain is associated with the development of eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased contraction intensity is unrelated to the severity of the preeclampsia. Typically, the client's temperature increases because of increased cerebral pressure. A decrease in temperature is unrelated to an impending seizure. Hyporeflexia is not associated with an impending seizure. Typically, the client would exhibit hyperreflexia.

22. Following an eclamptic seizure, the nurse should assess the client for which of the following? 1. Polyuria. 2. Facial flushing. 3. Hypotension. 4. Uterine contractions.

22. 4. After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor, because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

23. A client at 36 weeks' gestation begins to exhibit signs of labor after an eclamptic seizure. The nurse should assess the client for: 1. Abruptio placentae. 2. Transverse lie. 3. Placenta accreta. 4. Uterine atony.

23. 1. After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasoconstriction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and an abnormal fetal heart rate tracing. Transverse lie or shoulder presentation, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fluid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnormally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after childbirth, leading to postpartum hemorrhage.

3. The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement? 1. "If the fetus is becoming less active than before." 2. "If it takes longer each day for the fetus to move 10 times." 3. "If the fetus stops moving for 12 hours." 4. "If the fetus moves more often than 3 times an hour."

3. 4. The fetus is considered well if it moves more often than 3 times in 1 hour. Daily fetal movement counting is part of all high-risk assessments and is a noninvasive, inexpensive method of monitoring fetal well-being. The health care provider should be notified if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.

2. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. What further information should the nurse obtain to determine if this client is becoming preeclamptic? 1. Headaches. 2. Blood glucose level. 3. Proteinuria. 4. Edema in lower extremities.

3. The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. The preeclamptic client will have significant edema in the face and hands. Headaches are significant in pregnancy- induced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.

4. A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention is to: 1. Maintain continuous fetal monitoring. 2. Encourage family members to remain at bedside. 3. Assess reflexes, clonus, visual disturbances, and headache. 4. Monitor maternal liver studies every 4 hours.

4. 3. The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

5. At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (151.7 cm) has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45-kg) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia? 1. Total weight gain. 2. Shortstature. 3. Adolescent age group. 4. Proteinuria.

5. 3. Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with five or more pregnancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb (9.1 kg) at 32 weeks' gestation with a 1-lb (0.45-kg) weight gain in the last 2 weeks is within normal limits. Short stature is not associated with the development of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced hypertension.

1. A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?

50ml/hr

6. After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following? 1. Hydrocephalic infant. 2. Abruptio placentae. 3. Intrauterine growth retardation. 4. term-6. Poor placental perfusion.

6. 1. Congenital anomalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth retardation, and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction. Intrauterine growth retardation is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction.

17. Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the primary health care provider prescribes a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately? 1. Respiratory rate of 12 breaths/min. 2. Patellar reflex of +2. 3. Blood pressure of 160/88 mm Hg. 4. Urinary output exceeding intake.

7. 1. A respiratory rate of 12 breaths/min suggests potential respiratory depression, an adverse effect of magnesium sulfate therapy. The medication must be stopped and the primary health care provider should be notified immediately. A patellar reflex of +2 is normal. Absence of a patellar reflex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg would be a common finding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client receiving intravenous magnesium sulfate. Oliguria is more common.

7. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans? 7. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans? 1. 30-minute period three times a day.2. 45-minute period after lunch each day. 3. 1-hour period each day.4. 12-hour period each week.7. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been

7. 3. Numerous methods have been proposed to record the maternal perceptions of fetal movement or "kick counts." A commonly used method is the Cardiff count-to-10 method. The client begins counting fetal movements at a specified time (eg, 8:00 AM) and notes the time when the 10th movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10 to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement accurately. The client should monitor fetal movements more frequently than 1 time per week. One hour of monitoring each day is adequate.

8. When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which of the following types of diet should the nurse discuss? 1. High-residue diet. 2. Low-sodium diet. 3. Regular diet. 4. High-protein diet.

8. 3. For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

9. A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is treated as an outpatient. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following? 1. Blurred vision. 2. Ankle edema. 3. Increased energy levels. 4. Mild backache.

9. 1. Severe headache, visual disturbances such as blurred vision, and epigastric pain are associated with the development of severe preeclampsia and possibly eclampsia. These danger signs and symptoms must be reported immediately. Severe headache and visual disturbances are related to severe vasoconstriction and a severe increase in blood pressure. Epigastric pain is related to hepatic dysfunction. Ankle edema is common during the third trimester. However, facial edema is associated with increased fluid retention and the progression from mild to severe preeclampsia. Increased energy levels are not associated with a progression of the client's preeclampsia or the development of complications. In fact, some women report an "energy spurt" before the onset of labor. Mild backache is a common discomfort of pregnancy, unrelated to a progression of the client's preeclampsia. It also may be associated with bed rest when the mattress is not firm. Some multiparous women have reported a mild backache as a sign of impending labor.