Eclampsia Practice Question (Test #4, Fall 2020)
The nurse is evaluating the effectiveness of bedrest for a client with mild pre-eclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2+ proteinuria. 3. Decrease in plasma protein. 4. 3+ patellar reflexes.
1 1. Weight loss is a positive sign. 2. This client is losing protein. The nurse would evaluate a 0-to-trace amount of protein as a positive sign. 3. A decrease in serum protein is a sign of pathology. An increase in serum protein would be a positive sign. 4. 3+ reflexes are pathological. Normal reflexes are 2+. TEST-TAKING TIP: The key to answering this question is the test taker's ability to interpret the meaning of mild preeclampsia and to realize that this is an evaluation question. There are two levels of pre-eclampsia. Mild pre-eclampsia is characterized by the following signs/ symptoms: blood pressure 140/90, urine protein +2, patellar reflexes +3, and weight gain. As can be seen, the values included in answers 2 and 4 are the same as those in the diagnosis. They, therefore, are not signs that the pre-eclampsia is resolving. Similarly, loss of protein is not a sign of resolution of the disease.
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
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
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.Poor placental perfusion.
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.
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.
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.
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.
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.
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.
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.
During a prenatal interview, a client tells the nurse, "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? 1. "Does your mother have a family history of cancer?" 2. "Did your mother tell you what she was toxic from?" 3. "Does your mother have diabetes now?" 4. "Did your mother say whether she had a seizure or not?"
4 1. Toxemia is not related to a family history of cancer. 2. Toxemia is not related to a toxic substance. 3. Toxemia is not directly related to diabetes mellitus. 4. This is the appropriate question. The nurse is asking whether or not the client's mother developed eclampsia. TEST-TAKING TIP: The hypertensive illnesses of pregnancy used to be called toxemia of pregnancy as well as pregnancyinduced hypertension. The term toxemia is still heard in the community because the mothers and grandmothers of clients were told that they had toxemia of pregnancy. Because daughters of clients who have had pre-eclampsia are at high risk for hypertensive illness, it is important to fi nd out whether or not the client's mother had developed eclampsia.
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 rails.
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.
A client has been receiving magnesium sulfate for severe pre-eclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°F.
2 1. It is unlikely that an apical heart rate of 104 is responsible for the client's changes. 2. The urinary output is the likely cause of the client's changes. 3. It is unlikely that a blood pressure of 160/120 is responsible for the client's changes. 4. It is unlikely that a temperature of 100°F is responsible for the client's changes. TEST-TAKING TIP: The hourly output for this client is 20 mL/hr. This is well below the minimum urinary output of 30 mL/hr. Because the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. This client is exhibiting signs of magnesium toxicity.
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"
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
A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing, because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.
2 1. The results are not normal. This client's blood pressure is markedly elevated and the client is hyperreflexic. 2. The nurse should notify the physician of the signs of pre-eclampsia. 3. There is no need to discontinue the intravenous infusion. 4. The findings are consistent with signs of pre-eclampsia. It would be inappropriate to wait 15 minutes to verify the results. TEST-TAKING TIP: The hypertensive illnesses of pregnancy can develop at any time after 20 weeks' gestation through about 2 weeks postpartum. This client is exhibiting a late onset of pre-eclampsia— markedly elevated blood pressure and hyperrefl exia. The physician should be notifi ed as soon as possible of the changes.
A client is being admitted to the labor suite with a diagnosis of eclampsia. The fetal heart rate tracing shows moderate variability with early decelerations. Which of the following actions by the nurse is appropriate at this time? 1. Tape a tongue blade to the head of the bed. 2. Pad the side rails and head of the bed. 3. Provide the client with needed stimulation. 4. Provide the client with grief counseling.
2 1. This is not appropriate. Because it is dangerous for tongue blades to be inserted into the mouths of seizing clients, the nurse should not place a tongue blade in the client's room. 2. This is appropriate. The side rails and the headboard should be padded. 3. The room of an eclamptic client should be quiet. Excess stimulation can precipitate a seizure. 4. There is no reason to provide grief counseling to this client. TEST-TAKING TIP: When a client has been diagnosed with eclampsia, she has already had at least one seizure. The nurse, therefore, must be prepared to care for the client during another seizure. The most important action during the seizure is to protect the client from injury. Padding the side rails and headboard will provide that protection. This client's fetus is exhibiting a normal heart rate pattern.
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+.
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
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?"
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.
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).
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? 1. +1. 2. +2. 3. +3. 4. +4.
3 1. +1 reflexes are defined as hypo reflexic. 2. +2 reflexes are defined as normal. 3. +3 reflexes are defined as slightly brisker than normal or slightly hyperreflexic. 4. +4 reflexes are defined as much brisker than normal or markedly hyperreflexic. TEST-TAKING TIP: Although, as seen previously, a clear categorization of reflex assessment exists, the value assigned to a reflex by a clinician does have a subjective component. Therefore, it is recommended that at the change of shift both the new and departing nurses together assess the reflexes of a client who has suspected abnormal reflexes. A common understanding of the reflex
A client with mild pre-eclampsia who has been advised to be on bedrest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bedrest will help you to conserve energy for your labor." 2. "Bedrest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."
3 1. Bedrest for the pre-eclamptic client is not ordered so that she may conserve energy. 2. Pre-eclamptic clients rarely complain of nausea or anorexia. 3. Bedrest, especially side-lying, helps to improve perfusion to the placenta. 4. Although indirectly this response may be accurate, that is not the primary reason for the positioning. TEST-TAKING TIP: This question requires the nurse to have a clear understanding of the pathology of pre-eclampsia. Only with an understanding of the underlying disease can the test taker be able to remember the rationale for many aspects of client care. The vital organs of preeclamptic clients are being poorly perfused as a result of the abnormally high blood pressure. When a woman lies on her side, blood return to the heart is improved and the cardiac output is also improved. With improved cardiac output, perfusion to the placenta and other organs is improved.
A woman with severe pre-eclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations
3 1. Oxytocin is safe to administer if a client has pre-eclampsia. 2. The frequency is within normal limits. 3. The duration of the contractions is prolonged. The baby will be deprived of oxygen. 4. The FH is within normal limits. TEST-TAKING TIP: Not only is this client receiving oxytocin, but she is also preeclamptic. Pre-eclampsia is a vasoconstrictive disease state. The likelihood of poor placental perfusion is already high. When the contraction duration is also prolonged, the fetus is at high risk of becoming hypoxic.
A client is admitted to the hospital with severe pre-eclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor.
3 1. Patellar reflexes are assessed by striking the patellar tendon. 2. Clonus is not assessed by palpating the woman's ankle. 3. To assess clonus, the nurse should dorsiflex the woman's foot. 4. Clonus is not assessed by positioning the woman's feet fl at on the floor TEST-TAKING TIP: When clients have severe pre-eclampsia, they are often hyperreflexic and develop clonus. To assess for clonus, the nurse should dorsiflex the foot and then let the foot go. The nurse should observe for and count any pulsations of the foot. The number of pulsations is documented. The higher the number of pulsations there are, the more irritable the woman's central nervous system is
A nurse is counseling a pre-eclamptic client about her diet. Which should the nurse encourage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars
3 1. Sodium restriction is not recommended. 2. There is no need to increase fluid intake. 3. It is important for the client to eat a well-balanced diet. 4. Although not the most nutritious of foods, there is no need to restrict the intake of simple sugars. TEST-TAKING TIP: Clients with preeclampsia are losing albumin through their urine. They should eat a well-balanced diet with sufficient protein to replace the lost protein. Even though pre-eclamptic clients are hypertensive, it is not recommended that they restrict salt—they should have a normal salt intake—because during pregnancy the kidney is salt sparing. When salt is restricted, the kidneys become stressed.
A patient is placed on bedrest at home for mild pre-eclampsia at 38 weeks' gestation. Which of the following must the nurse teach the patient regarding her condition? 1. Eat a sodium-restricted diet. 2. Check her temperature 4 times daily. 3. Report swollen hands and face. p4. Limit fluids to 1 liter per day.
3 1. The client should be encouraged to have a normal sodium intake. 2. It is unnecessary for the client to assess her temperature. 3. The client should call her primary caregiver to report swollen hands and face. 4. The client should not limit her intake of fluids. TEST-TAKING TIP: Clients with mild pre-eclampsia who progress to severe pre-eclampsia usually develop swollen hands and face. The symptoms occur as a result of the third spacing of fl uid, which, in turn, occurs as a result of the reduced colloidal pressure in the vascular tree.
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of pre-eclampsia.
3 1. This temperature elevation does not indicate infection. 2. A low pulse rate is expected in the early postpartum period. 3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm. 4. Although the systolic pressure is slightly elevated, a BP of 130/80 is within normal limits. TEST-TAKING TIP: Even though explanations are provided for each of the signs, the test taker must be able to determine which explanation is correct and which are erroneous. If the test taker consciously stops to think about each of the signs before looking at the explanations, he or she is less likely to be swayed by a wrong answer.
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.
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.
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.
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.
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.
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
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).
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
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.
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.
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.
A client is on magnesium sulfate for severe pre-eclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.
4 1. Hyperreflexia is seen with severe preeclampsia. The magnesium sulfate is being administered to depress the hyperreflexia. 2. 30 mL/hr is an acceptable urinary output. 3. A respiratory rate of 16 rpm is within normal limits. 4. A serum magnesium level of 9 g/dL is dangerously high. The healthcare practitioner should be notified. TEST-TAKING TIP: When magnesium sulfate is being administered, the nurse should monitor the client for adverse side effects including respiratory depression, oliguria, and depressed refl exes. When the magnesium level is above 7 g/dL, toxic effects can be seen.
A client has severe pre-eclampsia. The nurse would expect the primary healthcare practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.
4 1. The fetus will not be assessed for signs of severe anemia. 2. The fetus will not be assessed for signs of hypoprothrombinemia. 3. The fetus will not be assessed for signs of craniosynostosis. 4. The fetus should be assessed for intrauterine growth restriction. TEST-TAKING TIP: Perfusion to the placenta drops when clients are pre-eclamptic because the client's hypertension impairs adequate blood fl ow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus's growth is affected.
A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm 3 and a hematocrit of 29%. Her laboratory values 1 week earlier were platelet count 200,000 cells/mm 3 and hematocrit 37%. Which additional abnormal laboratory value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).
4 1. The nurse would expect to see an elevated serum creatinine level, not a decreased level. 2. The nurse would expect to see a low RBC count, not an elevated one. 3. The nurse would expect to see an elevated alkaline phosphatase level, not a decreased one. 4. The nurse would expect to see an elevated ALT. TEST-TAKING TIP: This is a difficult, critical-thinking question. This client is exhibiting signs of HELLP syndrome (low platelets and hemolysis). Even though severe pre-eclampsia is not a part of the HELLP constellation, a client in severe pre-eclampsia would have poor renal function (elevated serum creatinine level). With hemolysis, the nurse would expect to see a drop in the RBC count and, with a damaged liver, an elevated alkaline phosphatase level as well as an elevated ALT level
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.
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.
A postoperative cesarean client who was diagnosed with severe pre-eclampsia in labor and delivery is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question? 1. Methergine (methylergonovine). 2. Magnesium sulfate. 3. Advil (ibuprofen). 4. Morphine sulfate
1 1. Methergine is contraindicated for this client. 2. Magnesium sulfate is the drug of choice for the treatment of severe pre-eclampsia. 3. Ibuprofen is a nonsteroidal anti-infl ammatory drug (NSAID). It is an appropriate medication for the treatment of postpartum cramping. It is not contraindicated for this client. 4. Morphine sulfate is a narcotic analgesic. It is an appropriate medication for the treatment of postsurgical pain. It is not contraindicated for this client. TEST-TAKING TIP: Methergine is an oxytocic agent. It acts directly on the myofi brils of the uterus. Secondarily, it also contracts the muscles of the vascular tree. As a result, clients' blood pressure tends to elevate when they receive this medication. Methergine should not be administered to a client whose blood pressure is 130/90 or higher.
A primipara, postpartum one day from a vaginal delivery, received magnesium sulfate in labor for severe pre-eclampsia. Which of the following healthcare referrals should the nurse recommend be made for the patient? Referral to: 1. Cardiologist. 2. Gastroenterologist. 3. Hepatologist. 4. Immunologist.
1 1. The client should be referred to a cardiologist. 2. There is no need for the client to be referred to a gastroenterologist. 3. There is no need for the client to be referred to a hepatologist. 4. There is no need for the client to be referred to an immunologist. TEST-TAKING TIP: Women who have been diagnosed with hypertensive illnesses of pregnancy are at high risk of developing cardiovascular disease. They should be monitored throughout their lives for signs of chronic hypertension, left ventricular dysfunction, right ventricular dysfunction, and the like (see Melchiorre, Sharma, & Thilaganathan, 2014).
A client who has been diagnosed with severe pre-eclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).
1 1. The nurse must have calcium gluconate in the client's room. 2. Morphine sulfate should not be in the client's room. It is a controlled substance. 3. Narcan does not have to be in the client's room. 4. Demerol should not be in the client's room. It is a controlled substance. TEST-TAKING TIP: Calcium gluconate is the antidote for magnesium sulfate toxicity. It is very important that the test taker know that, if needed, calcium gluconate must be administered very slowly. If calcium gluconate is administered rapidly, the client may experience sudden convulsions.
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with pre-eclampsia. In addition to obtaining baseline vital signs and placing the client on bedrest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.
1 1. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. 2. The blood count is important, but the nurse should first assess patellar reflexes. 3. The baseline weight is important, but the nurse should first assess patellar reflexes. 4. The urinalysis should be obtained, but the nurse should first assess patellar reflexes. TEST-TAKING TIP: Pre-eclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the urinalysis. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the preeclampsia. For example, if the reflexes are +2, the client would be much less likely to become eclamptic, that is, have a seizure, than a client who has +4 reflexes with clonus
A woman, 32 weeks' gestation, contracting every 3 min × 60 sec, is receiving magnesium sulfate. For which of the following maternal assessments is it critical for the nurse to monitor the client? 1. Low urinary output. 2. Temperature elevation. 3. Absent pedal pulses. 4. Retinal edema.
1 1. The urinary output should be carefully monitored. 2. Magnesium sulfate administration does not place clients at high risk for a temperature elevation. 3. Magnesium sulfate administration does not place clients at high risk for cessation of peripheral circulation. 4. Magnesium sulfate administration does not place clients at high risk for retinal edema. TEST-TAKING TIP: Even though this client is receiving magnesium sulfate to treat preterm labor and not pre-eclampsia, the medication still has the same side effects. Magnesium sulfate is excreted through the kidneys. If the urinary output drops, the concentration of magnesium sulfate can rise in the bloodstream. Because at toxic levels the client can experience respiratory depression and cardiac compromise, it is very important for the nurse carefully to monitor the client's urinary output.
A client is on magnesium sulfate via IV pump for severe pre-eclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.
1 1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. 2. Kernig's assessment is performed when checking for nuchal rigidity in a client with meningitis. 3. Pupillary responses are performed when a client has had a head injury or is not responsive. 4. Apical heart rate checks are performed when a client has a cardiac disease or is receiving digoxin. TEST-TAKING TIP: The only accurate way to assess for magnesium toxicity is to do a serum magnesium level. Normal magnesium levels are 1.8 to 3 mg/dL. Therapeutic levels are 4 to 8 mg/dL. Reflex depression begins to appear when the levels reach 8 to 12 mg/dL. When levels rise to 15 mg/dL or higher, respiratory depression and, eventually, cardiac arrest occur. Hourly grip strengths performed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. If changes are noted, the nurse can notify the healthcare provider, who can order a stat magnesium level.
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.T 98 (36.7), P 72, R 14. 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).
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.
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler position.
2 1. Eclamptic clients should be monitored for proteinuria, not for the presence of ketones. 2. The side rails of an eclamptic client's bed should be padded. 3. Eclamptic clients should be kept in a low stimulation environment. 4. There is no rationale for placing the head of an eclamptic patient's bed in high-Fowler position. The client should be moved to a side-lying position to improve uterine blood flow. TEST-TAKING TIP: Eclamptic clients have had at least one seizure. To protect them from injury during any potential subsequent seizures, the nurse should pad the headboard and the side rails of the client's bed.
A 29-week-gestation woman diagnosed with severe pre-eclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus.
2 1. At 29 weeks' gestation, the normal fundal height should be 29 cm. With severe preeclampsia, the nurse may see poor growth— that is, a fundal height below 29 cm. 2. The nurse would expect to see papilledema. 3. The nurse would expect to see hyperreflexia—that is, patellar reflexes higher than +2. 4. The nurse would not expect to see nystagmus. TEST-TAKING TIP: Increased intracranial pressure (ICP) is present in a client with severe pre-eclampsia because she is third spacing large quantities of fluid. As a result of the elevated ICP, the optic disk swells and papilledema is seen when the disk is viewed through an ophthalmoscope
A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective? 1. The client has had no seizures since delivery. 2. The client's blood pressure has dropped from 160/120 to 130/90. 3. The client's postoperative weight has dropped from 154 to 144 lb. 4. The client states that her headache is gone.
2 1. Hydralazine is administered as an antihypertensive, not as an antiseizure medication. Magnesium sulfate is the drug administered as an anticonvulsant to women with eclampsia. 2. Hydralazine is an antihypertensive. The change in blood pressure indicates that the medication is effective. 3. The weight loss is secondary to fluid loss. 4. The hydralazine is not administered to treat a headache. TEST-TAKING TIP: Hydralazine is an antihypertensive medication. Antihypertensive medications are administered to pre-eclamptic and eclamptic women whose blood pressures fail to drop with the administration of magnesium sulfate. The goal of the medication, therefore, is for the blood pressure to drop. A change in BP from 160/120 to 130/90 is evidence of a therapeutic effect
Which of the following physical findings would lead the nurse to suspect that a client with severe pre-eclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.
2 and 3 are correct. 1. A client with severe pre-eclampsia could exhibit symptoms of +3 pitting edema without the addition of HELLP syndrome. 2. Petechiae may develop when a client is thrombocytopenic, one of the signs of HELLP syndrome. 3.Hyperbilirubinemia develops when red blood cells hemolyze, one of the changes that may develop as a result of liver necrosis. Jaundice is a symptom of hyperbilirubinemia. Also, elevated liver function tests (EL) are a manifestation of HELLP syndrome. 4. +4 reflexes are consistent with a diagnosis of severe pre-eclampsia and may be present without the addition of HELLP syndrome. 5. Elevated specific gravity is consistent with a diagnosis of severe pre-eclampsia and may be present without the addition of HELLP syndrome. TEST-TAKING TIP: The test taker must be able to discriminate between symptoms of severe pre-eclampsia and HELLP syndrome. If the nurse remembers what each of the letters in HELLP stands for, he or she can determine which of the responses is correct.
An obese gravid woman is being seen in the prenatal clinic. The nurse will monitor this client carefully throughout her pregnancy because she is at high risk for which of the following complications of pregnancy? Select all that apply. 1. Placenta previa. 2. Gestational diabetes. 3. Deep vein thrombosis. 4. Pre-eclampsia. 5. Chromosomal defects.
2, 3, and 4 are correct. 1. Obese clients are not especially at high risk for placenta previa. 2. Obese clients are at high risk for gestational diabetes. 3. Obese clients are at high risk for deep vein thrombosis. 4. Obese clients are at high risk for pre-eclampsia. 5. Obese clients are not especially at high risk for chromosomal defects. TEST-TAKING TIP: Because clients who enter pregnancy obese are at high risk for type 2 diabetes, many obstetricians schedule an oral glucose tolerance test early in pregnancy rather than waiting until after 24 weeks' gestation. As a result, the complication is discovered much earlier and intervention can begin much earlier. The patients are also carefully monitored for signs and symptoms of pre-eclampsia and deep vein thrombosis .
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
2,3,4. Headaches could be a sign of preeclampsia/eclampsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyperreflexes, 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
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.Short stature. 3.Adolescent age group. 4.Proteinuria.
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
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.
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.
A gravid woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? Select all that apply. 1. Placenta previa. 2. Transverse fetal lie. 3. Placental abruption. 4. Severe pre-eclampsia. 5. Preterm labor
3 and 5 are correct. 1. Placenta previa is not an acute problem. It is related to the site of placental implantation. 2. Transverse fetal lie is a malpresentation. It would not be related to the auto accident. 3. Placental abruption may develop as a result of the auto accident. 4. Pre-eclampsia does not occur as a result of an auto accident. 5. The woman may go into preterm labor after an auto accident. TEST-TAKING TIP: The fetus is well protected within the uterine body. The musculature of the uterus and the amniotic fluid provide the baby with enough cushioning to withstand minor bumps and falls. A major automobile accident, however, can cause anything from preterm premature rupture of the membranes, to preterm labor, to a ruptured uterus, to placental abruption. The nurse should especially monitor the fetal heartbeat for any variations
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output is 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.
4 1. Completely depressed patellar reflexes are a sign of magnesium sulfate toxicity. This is not an expected outcome. 2. A normal urinary output is important, but it is not an expected outcome related to magnesium sulfate administration. 3. A normal respiratory rate is important, but it is not an expected outcome related to magnesium sulfate administration. 4. The absence of seizures is an expected outcome related to magnesium sulfate administration. TEST-TAKING TIP: Eclamptic clients have seized. Magnesium sulfate is ordered and administered to these clients because it is an anticonvulsant. An expected outcome of its administration, therefore, is that the client will have no more seizures.
A 26-week-gestation woman is diagnosed with severe pre-eclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.
4 1. The nurse would expect to see high serum creatinine levels associated with severe pre-eclampsia. 2. The nurse would expect to see low serum protein levels with severe pre-eclampsia. 3. Bloody stools are never associated with severe pre-eclampsia. 4. Epigastric pain is associated with the liver involvement of HELLP syndrome. TEST-TAKING TIP: The acronym, HELLP, stands for the following signs/symptoms: hemolysis, elevated liver enzymes, and low platelets. When the liver is deprived of sufficient blood supply, as can occur with severe pre-eclampsia, the organ becomes ischemic and liver enzymes become elevated. In addition, the client experiences pain at the site of the liver as a result of the hypoxia in the liver
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.
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
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."
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.
