Pre eclampsia
a nurse is completing an admission assessment of a client who is 38 weeks and has severe preeclampsia. What would be an expected finding.
A report of HA: Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.
ANIC4C who has severe preeclampsia 35 weeks of gestation and is reviewing the provider's orders. What oder would require clarification?
Ambulate 2x daily - A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow.
If a patient is being treated with mag sulfate IV and the resp rate is 10/min and deep tendon reflexes are absent what action should the nurse implement.
Discontinue the medication infusion - Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.
A nurse is assessing a client who is pregnant for pre-eclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
Elevated BP - Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.
ANIC4 adolescent client who is G1P1. Client was admitted at 38 weeks with Dx of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia. What findings would be expected?
Inconsistent: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia What a nurse should find with preeclampsia: an increased deep tendon reflex, 1+ pitting sacral edema, 3+ protein in urine (proteinuria), BP > or = to 140/90
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?
The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages. The client who has mild preeclampsia is encouraged to consume 60 to 70 g of protein, 1200 mg of calcium, 400 mcg of folic acid, and 2 to 6 g of zinc and sodium in her daily diet. Protein is needed for tissue integrity and calories. The client who has preeclampsia requires additional fiber in the diet, which should come from whole grain foods, raw fruits, and vegetables. Salt foods to taste but limit consumption of foods that are high in sodium, such as chips, pretzels, processed meats, and pickles.
ANIC4C who has severe preeclampsia and is receiving mag sulfate IV at 2gtt/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?
resp rate of 16/min - The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes Bradypnea & Bradycardia, and diminished/absent DTR. Based on this finding, the nurse may continue the infusion.
