ATI - Pregnancy & HTN Disorders 2017

A nurse is assessing a client who is receiving magnesium sulfate to treat preeclampsia. Which findings should nurse report to provider?

Fetal heart rate 158/min A fetal heart rate of 158/min is within the expected reference range The expected reference range for the fetal heart rate is 110/min to 160/min. Respirations 16/min A respiratory rate of 16/min is within the expected reference range for a client receiving magnesium sulfate. The acceptable range for respiratory rate is 16 to 20/min. Headache for 30 min Headaches and muscle weakness are expected reactions to magnesium sulfate administration. They do not require reporting to the provider. >>Urinary output 40 mL in 2 hr Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

Abruptio placentae

Premature separation of the placenta from the uterine wall

A nurse is caring for a client who has severe preeclampsia and is receiving mag sulfate IV at 2g/hr. Which finding indicates that it is safe to continue the infusion.

Respiratory rate of 16 Urine output of 50 mL in 4hr The client's urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium. The nurse should stop the infusion. Diminished deep-tendon reflexes Diminished or absent deep-tendon reflexes is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately. Heart rate of 56/min Bradycardia is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately. Respiratory rate of 16/min The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion.

Magnesium Sulfate Toxicity

Symptoms such as decreased or absent deep tendon reflexes, muscle weakness, visual disturbances or slurred speech. Discontinue infusion

A nurse is assessing a pregnant client for preeclampsia. Which finding requires further evaluation?

Vaginal discharge Vaginal discharge is not a manifestation of preeclampsia; it could indicate infection or oncoming labor (loss of mucous plug, bloody show). >>Elevated blood pressure Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine. Increased urine output With mild preeclampsia, urine output matches fluid intake, but with severe preeclampsia, urine output decreases. Joint pain Preeclampsia is more likely to cause headaches than joint pain.

preeclampsia symptoms

hypertension, proteinuria, vertigo, headache, or edema of the hands and face, increased deep tendon reflexes

A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

Abruptio placentae

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which is an expected finding?

Absence of clonus Manifestations of severe preeclampsia include presence of clonus and brisk deep tendon reflexes (3+, 4+). >>Report of headache 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. Tachycardia Manifestations of severe preeclampsia include hypertension, not tachycardia. Polyuria Manifestations of severe preeclampsia include decreased urine output and proteinuria, not polyuria.

A nurse is admitting a client Who is at 37 weeks of gestation and has severe gestational hypertension. Nurse should implement?

Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L. Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. Assess respiratory status every 4 hr is incorrect. The nurse should monitor the client's respiratory status closely because the client is at risk for respiratory depression. During an infusion of magnesium sulfate, the nurse should monitor the respiratory rate every 5 min and every 15 min during maintenance infusion. Depending on the client's response to the medication, the provider will prescribe for the vital signs to be monitored every 30 to 60 min thereafter. Evaluate neurologic status every 8 hr is incorrect. The nurse should evaluate the client's level of consciousness every hour. Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress.

A nurse is admitting a client Who has severe preeclampsia at 35 weeks. Which order requires clarification?

Ambulate twice daily Should be on bed rest in a quiet, non-stimulating environment to prevent seizures and promote optimal placental blood flow

A nurse is competing discharge teaching to a client who is in her 35th week of pregnancy

Drink 48 to 64 ounces of water daily Limit high sodium foods Increase fiber Avoid alcohol and caffeine 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.