HESI Case Study Preeclampsia Ashley Cash

15. Ashley's husband offers to sign the consent forms since she isn't feeling well right now. Which response by the RN is correct? "That would be fine. Please read over the forms before you sign." "If Ashley does not feel like signing, we just wait until she feels better." "Ashley does not have to sign the informed consent." "Ashley should sign the consent forms herself since she is the one receiving the care."

"Ashely should sign the consent forms herself since she is the one receiving the care." Ashley is the person who should sign the consent forms. By validating Ashley's role in informed consent and the decision-making process, the nurse enhances client empowerment.

6. While the RN is awaiting the lab results to determin if Ashely has elevatioin in liver function, diminished kidney function, or altered coagulopathies, which question should the RN ask Ashely? (Select all) "Do you have any dizziness?" "Do you have blurry vision?" "Do you have abdominal pain?" "Do you have cramping in your calf when you flex your leg?" "Do you have shortness of breath or chest discomfort?"

"Do you have any dizziness?" Increased peripheral resistance manifests itself as an elevated blood pressure, causing dizziness. "Do you have blurry vision?" Retinal arterial spasms may cause blurring or double vision, photophobia, or scotoma (spots before the eyes). "Do you have abdominal pain?" An increase in microvascular fat deposits within the liver is postulated as one of the causes of abdominal pain. "Do you have shortness of breath or chest discomfort?" Shortness of breath, chest tightness or discomfort, cough, or O2 saturation less than 95% could be signs or symptoms of pulmonary edema and could indicate worsening of preeclampsia.

4. Ashely's sister is concerned about the edema in her sister's face and hands. She asks the RN if the (HCP) will prescribe some of "those water pills" (diuretics) to help get rid of the excess fluid. Which response by the RN is correct? "That is a very good idea. I will relay it to the healthcare provider when I call." "I'm sorry, but it is not the family's place to make suggestions about medical treatment." "Let me explain to you about the effect of diuretics on pregnancy." "Have you by any chance given your sister water pills that belong to someone else?"

"Let me explain to you about the effect of diuretics on pregnancy. The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood volume. In the case of the preeclamptic client, this is particularly dangerous because the disease has already caused a volume deficit. In addition, the diuretics disrupt normal electrolyte balance and stress kidneys that are already compromised by preeclampsia. The only time they are used is if the preeclamptic client also has heart failure, but this client has no symptoms of heart failure.

26. Ashely's partner asks if some friends can come and watch television with him now that the baby has been born. Which response by the RN is most appropriate? "Absolutely not! Do you want to make her condition worse?" "You are a parent now. You have lots to learn while you're here." "Your wife is still at risk for complications, so visitors are limited to family members, and only for a short period of time." "Sure. I know they would love to see the new baby!"

"Your partner is still at risk for complications, so visitors are limited to family members, and only for a short period of time." This answer gives Ashley's husband the facts about her condition (still at risk for complications).

1. In reviewing Ashley's history, the RN is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Ashelys risk of developing preeclampsia? (Select all) -Molar pregnancy and history of preeclampsia in previous pregnancy. -Familial history. History of pounding headache, low socioeconomic status. Preexisting medical or genetic condition, such as Factor V Leiden. -Nulliparity.

-Familial history Ashley is older than 40 years of age and has a sister with a history of toxemia, which is an old term for preeclampsia that some clients may still use. -Preexisting medical or genetic condition, such as Factor V Leiden. Reasons for preeclampsia are unknown, but research shows that preexisting medical conditions and genetic conditions put the client at higher risk for preeclampsia. -Nulliparity. First pregnancy places a client at higher risk for preeclampsia than multiparity with the same partner.

5. After the RN establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000mL D5LR. The order from the HCP is oxytocin 2mU/min to augment labor. Calculate the drip rate for the oxytocin. (Whole number)

6 1/1000 x 2mu/1hr= 2000/20000= 0.10 x 60 min= 6mL/hr

10. The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced RN?

A 35-year-old gravida 3, para 2, with HELLP syndrome This client is the most critical among this group of clients and is at the highest risk for morbidity and mortality. HELLP syndrome occurs in only 2% to 12% of clients with severe preeclampsia.

11. What is the primary action of magnesium sulfate when given in preeclampsia? An antihypertensive. While there is some relaxation of blood vessel walls resulting in a slight decrease in the BP, magnesium sulfate is not an antihypertensive. If a pregnant client needs an antihypertensive, the drugs of choice are hydralazine or labetalol. A diuretic. Magnesium sulfate is not a diuretic. A CNS depressant. Magnesium sulfate depresses the CNS by interfering with the neuromuscular junction. It is given to prevent or control eclamptic seizures. A calcium channel blocker. Magnesium sulfate is not a calcium channel blocker.

A CNS depressant

14. The nurse asks Ashley if the HCP has discussed the labor and delivery processes, potential complications, and the management of those complications with her and if she understands them. Ashley replies, "I think so," and then asks for a pen. Which action should the nurse take? Witness the signatures after Ashley and her husband have signed the consent form. Call the HCP to explain all procedures again before asking Ashley to sign. Explain all the procedures and risks, and then ask Ashley to sign. Ask Ashley to explain what she understands about the procedures

Ask Ashley to explain what she understands about the procedures It is the responsibility of the nurse to ascertain what the client understands about the procedures and the potential risks associated with those procedures. If the client does not understand, the nurse must contact the HCP to clarify further for the client.

13. If magnesium toxicity is suspected, which medication should the nurse prepare to administer? Vitamin K. Calcium gluconate. Polystyrene sulfonate (Kayexalate). Corticosteroid.

Calcium gluconate If magnesium toxicity is suspected, the magnesium should be discontinued immediately and the nurse should prepare to administer calcium gluconate.

27. The nurse is aware that continued magnesium sulfate puts Ashley at risk for postpartum hemorrhage even though oxytocin is infusing. The nurse recognizes that which medication is safest for Ashley if a second drug is needed to treat postpartum hemorrhage? Carboprost tromethamine. Methylergonovine. Ergonovine. Leonurus.

Carboprost tromethamine This medication, a derivative of prostaglandin F2 alpha, may be administered intramuscularly, intramyometrially at cesarean birth, or intraabdominally after vaginal birth. When given intramuscularly in the postpartum period, the usual dose is 25 mg every 15 to 90 minutes for up to 8 doses. This drug may be used with the hypertensive client.

9. If Ashely had HELLP syndrome, which lab results would the RN expect to see? Elevated hemoglobin and hematocrit without burr cells, elevated liver enzymes, and decreased creatinine clearance. Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased creatinine clearance. Elevated hemoglobin and hematocrit with burr cells, decreased liver enzymes, and creatinine clearance 120 mL/min. Decreased hemoglobin and hematocrit without burr cells, decreased liver enzymes, and creatinine clearance 134 mL/min.

Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, and decreased creatinine clearance. All of these indicate HELLP syndrome. HELLP stands for: hemolysis (H), evidenced by burr cells or an elevated bilirubin level; elevated liver enzymes (EL), evidenced by elevated AST and ALT; and decreased creatinine clearance.

7. Which technique should the RN use when evaluating Ashely's blood pressure while Ashely is on bedrest? Have Ashley lie supine and take the blood pressure on the left arm. Have Ashley lie in a lateral position and take the blood pressure on the dependent arm. Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. Have Ashley stand briefly and take the blood pressure on the right arm.

Have Ashely lie in a lateral position and take the blood pressure on the dependent arm The lateral position supports placental perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the blood pressure should be taken in that arm. This more closely approximates arterial pressure. Using the arm on the opposite (upper) side will falsely reduce the measurement.

24. The NICU RN anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate? Hyperreflexia and increased respirations. Hyporeflexia and irregular respirations. Hyporeflexia and decreased respirations. Hyperreflexia and irregular respirations.

Hyporeflexia and decreased respirations Because magnesium sulfate crosses the placenta, the newborn can develop toxic levels of magnesium. Neonatal hypermagnesemia manifests as hypotonia and a marked decrease in respiratory rate. This is not to be confused with irregular respirations, which are common in all infants. Hypermagnesemia may be treated with calcium and exchange transfusion with citrated blood and/or assisted mechanical ventilation until serum levels are normal. As with the mother, magnesium is cleared through the kidneys.

22. For which complication is Ashley most at risk following the epidural with a local anesthestic, such as bupivacaine or ropivacaine? Respiratory depression. Elevated temperature. Hypotension. Spinal headache.

Hypotension Hypotension occurs as a result of the sympathetic blockade. It is a common occurrence after an epidural if the mother is not adequately pre-hydrated or already has an impaired fluid volume, as Ashley does due to her preeclampsia. It can be prevented by adequate pre-load. For clients at risk for fluid overload, the use of central monitoring is indicated. The use of the side-lying position will also aid in preventing hypotension due to vena cava compression that occurs in the supine position. Ephedrine is the vasopressor of choice should severe hypotension occur. However, it is given only after fluid volume replacement, oxygen administration, and lateral positions have been implemented but were unsuccessful.

20. What should the RN do next to ensure intrauterine resuscitation? Implement a prescribed fluid bolus to improve maternal blood volume. Increase the oxytocin infusion rate to hasten the birth. Elevate the head of the bed 90 degrees to improve cardiac output. Decrease the magnesium sulfate rate to improve uterine contractility.

Implement a prescribed fluid bolus to improve maternal blood volume A bolus of non-dextrose IV fluid (normal saline or Ringer's lactated) will increase the maternal fluid volume, thereby improving blood flow and oxygenation to the fetus. Ashley already has a decrease in volume, secondary to her preeclampsia. For Ashley, the bolus will be carefully controlled because of her decreased kidney function.

8. When performing a nonstress test, the RN will be assessing for which parameters? It evaluates the heart rate of the fetus in response to its own movements. It measures the oxygen levels of the fetus. Accelerations of the fetal heart rate in response to uterine contractions. Late decelerations of the fetal heart rate in response to uterine contractions.

It evaluates the heart rate of the fetus in response to its own movement. The basis for the nonstress test is that the normal fetus with an intact central nervous system (CNS)will respond to fetal movements with an increased heart rate (episodic accelerations). A reactive test is one in which the fetus displays at least two accelerations of 15 beats per minute that last for 15 seconds in a 20-minute period in the presence of a normal baseline rate and moderate variability.

19. The RN recognizes what type of periodic fetal heart rate change that is occurring? Variable decelerations. Early decelerations. Transient bradycardia. Late decelerations.

Late decelerations Late decelerations are caused by uteroplacental insufficiency. Late decelerations are characterized by a gradual decrease from the baseline that begins after the contraction has started and does not return to baseline until after the contraction ends. Persistent late decelerations usually indicate fetal hypoxemia and can progress to hypoxia and acidemia. In Ashley's case, the late decelerations stem from the eclamptic seizure, during which the oxygen supply to the mother and fetus was compromised.

12. What information should be included in the client family teaching of magnesium sulfate? Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. This medication will be given intramuscular. Magnesium sulfate increases the risk of having seizures. Magnesium sulfate may cause hyperactivity.

Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. If renal function declines, not all of magnesium sulfate will be excreted, resulting in magnesium toxicity.

25. Ashley remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released Ashley from the postanesthesia care unit. Which room and nursing staff assignments should be made for Ashely? Move Ashley to the mother/baby unit and assign an RN with two other mother/baby couplets to care for her. Keep Ashley in recovery with an RN who is also caring for four other recovering mothers. Move Ashley to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her. Move Ashley to the Intensive Care unit (ICU) where an RN with one other client can care for her.

Move Ashely to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her A quiet room with one-to-one care is the most appropriate assignment. Clients with preeclampsia, even if they have not seized prior to birth, remain at risk for seizures. Magnesium is continued for at least 12 to 24 hours, based on the client's condition. Close assessment, including frequent vital sign monitoring, reflex checks, and I&O measurement is necessary. In addition, since magnesium relaxes smooth muscle, Ashley is at greater risk for postpartum hemorrhage.

2. To accurately assess this client's condition, what information from the prenatal record is most important for the RN to obtain? Pattern and number of prenatal visits. Prenatal blood pressure readings. Prepregnancy weight. Ashley's Rh factor.

Prenatal blood pressure reading The client's blood pressure (BP) (138/88) is below the guideline that indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of 140/90 taken on two occasions 6 hours apart. However, Ashley's reading is significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal levels, particularly in combination with proteinuria, blurry vision, epigastric pain and hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the same during the first trimester. Both systolic and diastolic then decrease gradually up to 20-weeks' gestation. At 20 weeks' gestation, the blood pressure begins to gradually increase and return to 1st trimester levels at term.

21. How should Ashley be positioned to receive epidural? Supine with feet in stirrups. Seated on edge of bed, slightly bent forward with legs dangling. Prone position. Semi-fowlers.

Seated on the edge of bed, slightly bent forward with legs dangling

17. When the RN evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change? Cord compression is occurring due to oxytocin crossing the placenta. The fetus' head is descending further into the pelvis. The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated. The mother's hypertension has caused an acute stress incident in the fetus.

The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated. Because magnesium sulfate crosses the placenta, the baby will have a magnesium level equal to the mother. Although sources differ on the effect that magnesium levels have on long-term variability, many sources do attribute a decrease in long-term variability to magnesium sulfate. Other sources state that magnesium sulfate does not affect fetal heart rate variability in a healthy term fetus whose weight is normal for gestational age. However, this fetus is preterm (36 weeks), and all fetuses of mothers with hypertensive diseases during pregnancy are at risk for intrauterine growth restriction related to poor placental perfusion.

16. Ashely asks why the magnesium sulfate was increased. What explanation should the RN provide? The magnesium is being excreted through the kidneys. The anxiety caused by labor contractions is affecting the drug's efficacy. The HCP should have also ordered an antihypertensive. The oxytocin is having an adverse interaction with the magnesium.

The magnesium is being excreted through the kidneys The magnesium level is not up to therapeutic range (4 to 7 mEq/L) because it is being excreted from the body.

Nursing Process: Planning Prior to initiating the HCP's prescription, the nurse must first obtain consent for vaginal and cesarean birth, analgesia and anesthesia, and blood transfusion. The HCP prescribes this plan of care for Ashley: Obtain permits for vaginal birth, cesarean birth, analgesia/anesthesia, and blood transfusion.Start on magnesium sulfate (4 g bolus over 20 min, then 1 g/hr per pump) per unit protocol.Follow standing magnesium sulfate protocol (may vary by hospital):Primary IV: Lactated Ringer's solutionTotal fluid volume: 150 mL/hourInsert Foley catheter with urimeter attachment for hourly I&OBed restVital signs & DTRs hourly after stabilized on magnesium sulfateContinuous uterine and fetal monitoringCalcium gluconate at bedsideBegin oxytocin induction per protocol.

The primary line (nonadditive, or maintenance line) on the left side of the pole contains no medication. The secondary line with the orange "medication added" label contains oxytocin. The secondary oxytocin line is regulated by the infusion pump and is inserted into the lowest port in the primary fluid line. An external fetal monitor is used to assess the fetal response to oxytocin-stimulated contractions. The woman lies on her side to promote uterine blood flow.

18. At 0930 Ashely's sister rings the call bell and yells, "Come quickly, Jennie is shaking all over." The RN determines that Jennie is experiencing an eclamptic seizure. Which nursing intervention takes priority? Observe fetal monitor for non-reassuring patterns of fetal heart rate. Turn Ashley onto her side and place a pillow behind her to stabilize the position. Make a note of the time and sequence of the eclampsia seizure. Suction the mouth, or oropharynx, and then apply oxygen at 10 liters per minute by facemask.

Turn Ashely onto her side and place a pillow behind her to stabilize the position Aspiration is the leading cause of maternal morbidity and mortality after an eclamptic seizure. By turning Ashley to a lateral position and using a pillow to hold that position, the RN can ensure that a patent airway is maintained, the aspiration of vomitus is minimized, and supine hypotension is prevented.

23. What should the RN tell Ashley? When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides. When the contraction begins on the fetal monitor, take a deep breath and hold it while bearing down for 10 seconds. Then take a quick breath and repeat the pushing pattern until the contraction ends on the monitor. When the nurse palpates a contraction's beginning, take three shallow breaths and hold the breath for as long as possible while bearing down without allowing air to escape. When the urge to push is felt, more of the epidural analgesic should be injected and the RN will tell the client when and how to push each time there is a contraction.

When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides. This method of pushing utilizes both instinctive, spontaneous pushing and open-glottis pushing. It is physiologically correct in that it utilizes Ferguson's reflex (the urge to bear down), at which time more oxytocin is released from the exterior pituitary to strengthen bearing-down contractions. Exhalation while pushing, limiting the amount of time breath is held, and taking deep breaths in between pushing efforts help maintain adequate oxygenation to the mother and fetus. This technique results in approximately 5 pushes during each contraction and is less likely to overtire the mother. This is in opposition to closed-glottis (prolonged breath-holding while pushing) technique, which may trigger the Valsalva maneuver. If that occurs, the increased intrathoracic and cardiovascular pressures reduce cardiac output and diminish perfusion of oxygen across the placenta, putting the fetus at risk for hypoxia.

3. What is the pathophysiology responsible for Ashely's complaint of a pounding headache and the elevated DTRs? Cerebral edema. Increased perfusion to the brain. Severe anxiety. Retinal arteriolar spasms.

cerebral edema As fluid leaks into the extravascular spaces, organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increased deep tendon reflexes, and clonus.