Preeclampsia nursing 211

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

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

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A. Any bleeding, such as in the gums, petechiae, and purpura. B. Enlargement of the breasts. C. Periods of fetal movement followed by quiet periods. D. Complaints of feeling hot when the room is cool.

A. Any bleeding, such as in the gums, petechiae, and purpura. Severe preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D. Option B: Estrogen stimulates growth of the breast duct cells and generates the secretion of prolactin, another hormone. Prolactin stimulates breast enlargement and milk production. Progesterone supports the formation and growth of milk-producing cells within the glands of the breasts. Option C: The first fetal movements which are felt by the mother are called quickening. One function of these movements is to alert the pregnant woman that she has a fetus growing in her uterus. Most providers recommend that pregnant women monitor fetal movements, especially by the third trimester. This can be accomplished by simply instructing the woman to have a general awareness of the fetus and determine if the fetus is moving less than normal on any given day or about the same as other days. Option D: At the beginning of your pregnancy, new hormones are like little workers that help keep everything humming along smoothly. These hormonal changes also raise your body temperature a small amount.

A nurse is caring for a newly admitted 32-week pregnant client with a blood pressure of 150/92, proteinuria, and severe right upper quadrant pain. The nurse knows that which of the following is a possible reason for this? A. Liver inflammation B. Constipation C. Gallstones D. Fetal position

A. Liver inflammation RUQ pain in pregnant clients with signs of preeclampsia is most often caused by liver inflammation. Constipation RUQ pain in clients with signs of preeclampsia is most often caused by liver inflammation, not gallstones.Gallstones Constipation pain most often occurs in the LLQ. Fetal position Fetal positioning could cause discomfort in any quadrant, but RUQ pain in clients with signs of preeclampsia is most often caused by liver inflamma

A woman with gestational hypertension experiences a seizure. Which of the following would be the priority?A) Fluid replacementB) OxygenationC) Control of hypertensionD) Delivery of the fetus

Ans: BAs with any seizure, the priority is to clear the airway and maintain adequate oxygenation both to the mother and the fetus. Fluids and control of hypertension are addressed once the airway and oxygenation are maintained. Delivery of fetus is determined once the seizures are controlled and the woman is stable.

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation B. Is an invasive test; however, contractions are stimulated C. Is considered negative if no late decelerations are observed with the contractions D. Is more effective than nonstress test (NST) if the membranes have already been ruptured

C. Is considered negative if no late decelerations are observed with the contractions No late decelerations indicate a positive CST.

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A. Monitor maternal vital signs every 2 hours. B. Notify the physician if respirations are less than 18 per minute. C. Monitor renal function and cardiac function closely. D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose. E. Monitor deep tendon reflexes hourly. F. Monitor I and O's hourly. G. Notify the physician if urinary output is less than 30 ml per hour.

C. Monitor renal function and cardiac function closely. D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose. E. Monitor deep tendon reflexes hourly. F. Monitor I and O's hourly. G. Notify the physician if urinary output is less than 30 ml per hour.

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician? A. Blood pressure reading is at the prenatal baseline. B. Urinary output has increased. C. The client complains of a headache and blurred vision. D. Dependent edema has resolved.

C. The client complains of a headache and blurred vision. If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening preeclampsia. Option A: In normal pregnancy, women's mean arterial pressure drops 10-15 mm Hg over the first half of pregnancy. Most women with mild chronic hypertension (ie, SBP 140-160 mm Hg, DBP 90-100 mm Hg) have a similar decrease in blood pressures and may not require any medication during this period. Option B: In addition to rising hormones, the body's fluid levels start to increase during pregnancy. This means the kidneys have to work extra hard to flush the extra fluid. The amount of urine released will increase as well. In the third trimester, the baby's growing size means they're pressing even more on the bladder. Option D: During normal pregnancy total body water increases by 6 to 8 liters, 4 to 6 liters of which are extracellular, of which at least 2 to 3 liters are interstitial. At some stage in pregnancy 8 out of 10 women have demonstrable clinical edema.

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A. Monitor maternal vital signs every 2 hours B. Notify the physician if respirations are less than 12 per minute C. Monitor renal function and cardiac function closely D. Keep calcium gluconate on hand in case of a magnesium sulfate overdose E. Monitor deep tendon reflexes hourly F. Monitor I and O's hourly G. Notify the physician if urinary output is less than 30 ml per hour.

Correct Answer(s)B. Notify the physician if respirations are less than 18 per minuteC. Monitor renal function and cardiac function closelyD. Keep calcium gluconate on hand in case of a magnesium sulfate overdoseE. Monitor deep tendon reflexes hourlyF. Monitor I and O's hourlyG. Notify the physician if urinary output is less than 30 ml per hour. ExplanationWhen caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A. Urinary output of 20 ml since the previous assessment B. Deep tendon reflexes of 2+ C. Respiratory rate of 10 BPM D. Fetal heart rate of 120 BPM

Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. Option A: A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. The kidneys face remarkable demands during pregnancy, and it is critical that the practicing nephrologist understands the normal kidney adaptations to pregnancy. GFR rises early to a peak of 40% to 50% that of prepregnancy levels, resulting in lower levels of serum creatinine, urea, and uric acid. There is a net gain of sodium and potassium, but a greater retention of water, with gains of up to 1.6 L. Option B: Deep tendon reflexes of 2+ are normal. With preeclampsia, a woman's reflexes become unusually active. Increasing blood pressure will lead to increasing hyperreflexia until uncontrollable seizures eventually result. Testing for this change is difficult in the field setting; in a clinic setting an overactive patellar response is a good indicator. Option D: The fetal heart rate is WNL for a resting fetus. Current international guidelines recommend for the normal fetal heart rate (FHR) baseline different ranges of 110 to 150 beats per minute (bpm) or 110 to 160 bpm

. A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient's education? Select all that apply: A. Report weight gain of >4 lbs in one week to physician B. Incorporate foods like eggs, nuts, fish, meat in your diet C. Follow a no salt diet D. Headache and vision changes are expected side effects of this condition and cause no reason for concern. E. Importance of monitoring urine protein at home F. Lying on left-side is recommended along with rest G. Report a decrease in fetal activity immediately

The answers are: B, E, F, and G. These options are topics the nurse wants to include in the patient's teaching with preeclampsia. Option A is wrong because the patient should report a weight gain of >2 lbs (NOT 4 lbs) in one week. Option C is wrong become it is no longer recommended the patient restrict salt in diet but limit it. Option D is wrong because a headache and vision changes are serious complications that may indicate the development of eclampsia, and the patient should report it immediately.

A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from preeclampsia to eclampsia, the nurse's first action is to: A. Administer magnesium sulfate intravenously B. Assess the blood pressure and fetal heart rate. C. Clean and maintain an open airway. D. Administer oxygen by face mask.

The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased. Option A: In this case, the doctor may prescribe magnesium sulfate as well as medications to help reduce blood pressure. Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia. It can also help prolong a pregnancy for up to two days. Option B: Preeclampsia is when the blood pressure, or the force of blood against the walls of the arteries, becomes high enough to damage the arteries and other blood vessels. Damage to the arteries may restrict blood flow. It can produce swelling in the blood vessels in the brain and to the growing baby. If this abnormal blood flow through vessels interferes with the brain's ability to function, seizures may occur. Option D: The initial treatment for eclampsia includes maintaining oxygen delivery to both mother and fetus, minimizing the risk of aspiration, treating the seizure, and controlling hypertension.

A 26-year old multigravida is 14 weeks pregnant and is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this test can detect: A. Kidney defects B. Cardiac defects C. Neural tube defects D. Urinary tract defects

C. Neural tube defects

Which of the following would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia?A) Calcium gluconateB) Potassium chlorideC) Ferrous sulfateD) Calcium carbonate

Ans: AThe antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the woman has signs and symptoms of magnesium toxicity.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A. Ankle clonus is noted. B. The blood pressure decreases. C. Seizures do not occur. D. Scotomas are present.

C. Seizures do not occur.

The nurse is assessing a client with mild preeclampsia to see if she has progressed to severe preeclampsia. Which of the following would be associated with the progression of this disease process? Select all that apply. A. OliguriaB. Visual changesC. Right upper quadrant painD. Elevated liver function testsE. Creatinine 0.04

Elevated liver function tests This is an indication that preeclampsia is progressing. Right upper quadrant pain This, along with oliguria, headache, fetal growth restriction are some of the signs of progression of the condition. Visual changes This is a sign of progressing preeclampsia.

. The nurse knows that preeclampsia tends to occur during what time in a pregnancy? A. before 20 weeks B. in the third trimester and postpartum C. after 20 weeks D. in the first and second trimester

The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.

A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician? A. Deep tendon reflex 4+ B. Respiratory rate of 13 breaths per minute C. Urinary output of 600 mL over 12 hours D. Clonus presenting in the lower extremities E. Patient reports flushing or feeling hot

The answer is E. The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.

The nurse expects to see which maternal cardiovascular finding during labor? a. decreased BPb. Dereased Pulse c. Decreased WBCd. Increased Cardiac Output

d. Increased Cardiac Output

When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which of the following would be most appropriate?A) Monthly visits until 32 weeks, then bi-monthly visitsB) Bi-monthly visits until 28 weeks, then weekly visitsC) Monthly visits until 20 weeks, then bi-monthly visitsD) Bi-monthly visits until 36 weeks, then weekly

Ans: BFor the woman with chronic hypertension, antepartum visits typically occur every 2 weeks until 28 weeks' gestation and then weekly to allow for frequent maternal and fetal surveillance.

The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the woman's increased risk?A) OligohydramniosB) PreeclampsiaC) Post-term laborD) Chorioamnionitis

Ans: BWomen with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios, hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple gestations and the development of chorioamnionitis.

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?A) Urinary output of 20 mL per hourB) Respiratory rate of 10 breaths/minuteC) Deep tendons reflexes 2+D) Difficulty in arousing

Ans: CWith magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than 12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.

A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A. A sleepy, sedated affectB. A respiratory rate of 10 breaths/min C. Deep tendon reflexes of 2+D. Absent ankle clonus

B. A respiratory rate of 10 breaths/min A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity.

The developing cells are called a fetus from the: A. Time the fetal heart is heard B. Eighth week to the time of birth. C. Implantation of the fertilized ovum. D. End of the send week to the onset of labor.

B. Eighth week to the time of birth

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

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

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

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

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A. Elevated blood pressure B. Negative urinary protein C. Facial edema D. Increased respirations

Correct Answer(s)A. Elevated blood pressureC. Facial edema ExplanationThe three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

1. The nurse knows that preeclampsia tends to occur during what time in a pregnancy? A. before 20 weeks B. in the third trimester and postpartum C. after 20 weeks D. in the first and second trimester

The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.

Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby? A. Acetylcysteine B. Calcium carbonate C. Oxytocin D. Calcium gluconate

The answer is D: The antidote for Magnesium Sulfate is Calcium Gluconate. The nurse should have this on hand in case Magnesium toxicity occurs.

After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension?A) Mother had gestational hypertension during pregnancy.B) Client has a twin sister.C) Sister-in-law had gestational hypertension.D) This is the client's second pregnancy.

Ans: AA family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in her second pregnancy.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. Which level would the nurse identify as therapeutic?A) 3.3 mEq/LB) 6.1 mEq/LC) 8.4 mEq/LD) 10.8 mEq/L

Ans: B Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic.

The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following findings would alert the nurse to the development of HELLP syndrome?A) HyperglycemiaB) Elevated platelet countC) LeukocytosisD) Elevated liver enzymes

Ans: DHELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or leukocytosis is not a part of this syndrome.

With regard to preeclampsia and eclampsia, nurses should be aware that: A. Preeclampsia is a condition of the first trimester; eclampsia is a condition of the second and third trimesters B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain C. The causes of preeclampsia and eclampsia are well documented D. The causes of preeclampsia and eclampsia are unknown, although several have been suggested.

B. Preeclampsia results in decreased function in such organs as the placenta, kidneys, liver, and brain Vasospasms diminish the diameter of blood vessels, which impedes blood flow to all organs.

How is Chronic Hypertension characterized?

elevated blood pressure in mother that predated pregnancy -can also be diagnosed when preeclampsia or gestational hypertension fails to normalize after delivery

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for preeclampsia. The nurse checks the client for which specific signs of preeclampsia? Select all that apply. A. Elevated blood pressure B. Negative urinary protein C. Facial edema D. Increased respirations

A. Elevated blood pressure C. Facial edema

How is Gestational Hypertension characterized?

blood pressure > 140/90 on 2 separate occasions at least 6 hours apart with no protein in the urine, and at least 20 weeks

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

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

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

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

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1.) Proteinuria 2.)Hypertension 3.)Low-grade fever 4.)Generalized edema5).Increased pulse rate6.)Increased respiratory rate

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

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

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

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

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

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1.) Tongue blade 2.) Percussion hammer3.)Potassium chloride injection 4.)Calcium gluconate injection

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

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

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

A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A. Hydralazine B. Magnesium sulfate bolusC. DiazepamD. Calcium gluconate

A. Hydralazine Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia.

A nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is: A. Hypertension B. Hyperemesis gravidarumC. Hemorrhagic complicationsD. Infections

A. Hypertension Preeclampsia and eclampsia are two noted, deadly forms of hypertension. Hypertension is the most common medical complication of pregnancy.

After the first four months of pregnancy, the chief source of estrogen and progesterone is the: A. Placenta B. Adrenal cortex C. Corpus luteum D. Anterior hypophysis

A. Placenta

A woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the client is having an adverse effect associated with this drug?A) Gastrointestinal bleedingB) Blurred visionC) TachycardiaD) Sweating

Ans: CHydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating.

A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the client has developed severe preeclampsia?A) Urine protein 300 mg/24 hoursB) Blood pressure 150/96 mm HgC) Mild facial edemaD) Hyperreflexia

Ans: DSevere preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild preeclampsia.

A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: A. Blood pressure is reduced to prepregnant baseline B. Seizures do not occur C. Deep tendon reflexes become hypotonic D. Diuresis reduces fluid retention

B. Seizures do not occur Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity.

3. You're providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops? A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta." B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter." C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs." D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia."

B. This is the only correct statement. When preeclampsia occurs it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom's circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.

Nurses should be aware that HELLP syndrome: A. Is a mild form of preeclampsia B. Can be diagnosed by a nurse alert to its symptoms C. Is characterized by hemolysis, elevated liver enzymes, and low platelets D. Is associated with preterm labor but not perinatal mortality

C. Is characterized by hemolysis, elevated liver enzymes, and low platelets The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP).

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine if the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

Predisposing Factors of Hypertensive disorders during pregancy

Nulliparity(never given birth)- Multiple gestation- Diabetes- Age(< 18 or > 35)- Chronic hypertension

A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure? A. Placing the patient in a supine position B. Holding down the patient's head to prevent injury C. Staying with the patient and activating the emergency response team D. Timing the seizure E. Providing 8 to 10 L of oxygen

The answers are A and B. The nurse would want to place the patient on their side (preferably the left- side...not supine) to help prevent the tongue from obstructing the airway, preventing aspiration, and improving blood flow to the placenta. In addition, the nurse would NOT want to restrain the patient, which can cause injury. Option C, D, and E are steps the nurse would want to take.

. A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply: A. 1600: blood pressure 144/100, 1700: blood pressure 120/ B. 3+ dipstick urine protein C. 1 hour glucose tolerance test 90 mg/dL D. 0800: blood pressure 142/92, 1230: blood pressure: 144/ E. <300 mg/dL 24-hour urine protein

The answers are B and D. Signs and symptoms of preeclampsia include: proteinuria (>1+ dipstick urine protein or >300 mg/dL 24 hour urine protein, hypertension >140/90.. reading at least 4-6 hours apart), swelling in face, eyes, extremities, headaches, vision changes, etc.