PrepU Query Quiz: Perfusion: Preeclampsia

The nurse is planning care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first? A: an 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has abdominal cramps B: a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm C: a 16-year-old G1 P1 with a caesarean section 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h; reflexes are 2+, and the nurse's notes indicate she has a headache; vital signs are T 99.4 F (37.4 C), P 88, R 20, BP 128/86 mm Hg D: an 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain; vital signs are T 99.8 F (37.7 C), P 96, R 22

B: a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm Explanation: The criteria for hemorrhage is saturating one pad per hour. The 35-year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration, which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding. The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication. The 16-year-old status post cesarean section on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client. The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent.

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? A: 30-minute period three times a day. B: 45-minute period after lunch each day. C: 1-hour period each day. D: 12-hour period each week.

C: 1-hour period each day. Explanation: 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 (e.g., 8:00 a.m.) 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.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? A: Insert an airway to improve oxygenation. B: Note the time when the seizure begins and ends. C: Call for immediate assistance. D: Turn the client to her left side.

C: Call for immediate assistance. Explanation: Principles of emergency management begin with calling for assistance. 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.

At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (157.5 cm) tall 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 factors increases her risk for preeclampsia? A: total weight gain B: short stature C: adolescent age group D: proteinuria

C: adolescent age group Explanation: 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.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? A: abruptio placentae B: HELLP syndrome C: disseminated intravascular coagulation D: threatened abortion

C: disseminated intravascular coagulation Explanation: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae, such as sharp pain and "woody," firm consistency of the abdomen (abruption). HELLP syndrome is a complication of preeclampsia that does not occur before 20 weeks gestation unless a molar pregnancy is present. There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding.

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 finding would alert the nurse that the client may be about to experience a seizure? A: decreased contraction intensity B: decreased temperature C: epigastric pain D: hyporeflexia

C: epigastric pain Explanation: 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.

Which finding provides the most evidence that a fetus might have a gastrointestinal tract anomaly? A: meconium in the amniotic fluid B: low implantation of the placenta C: increased amount of amniotic fluid D: preeclampsia in the last trimester

C: increased amount of amniotic fluid Explanation: Maternal hydramnios occurs when the fetus has a congenital obstruction of the gastrointestinal tract, such as in the presence of a tracheoesophageal fistula. The fetus normally swallows amniotic fluid and absorbs the fluid from the gastrointestinal tract. Excretion then occurs through the kidneys and placenta. Most fluid absorption occurs in the colon. Absorption cannot occur when the fetus has a gastrointestinal obstruction. Meconium in the amniotic fluid, low implantation of the placenta, and preeclampsia could occur but are more specifically associated with fetal hypoxia.

A 16-year-old primigravida at 35 weeks' gestation in active labor with severe preeclampsia is admitted to the hospital's labor unit. The nurse should notify the primary care provider immediately about which finding? A: 2+ deep tendon reflexes B: 3+ proteinuria C: platelet count of 80,000/mcL (80 X 109/L) D: clear to whitish vaginal discharge

C: platelet count of 80,000/mcL (80 X 109/L) Explanation: A platelet count of less than 100,000/mcL (100 X 109/L) indicates thrombocytopenia, a component of HELLP syndrome. HELLP syndrome, which consists of hemolysis, elevated liver enzymes, and low platelet count, is associated with severe pre-eclampsia. Notifying the primary health care provider immediately is crucial because this syndrome is associated with high rates of morbidity and mortality for the mother and her fetus. Deep tendon reflexes of 2+ are normal and not a cause of concern. The client has severe pre-eclampsia, so proteinuria of 3+ to 4+ would be expected. A clear to whitish vaginal discharge is a normal finding

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which type of diet should the nurse discuss? A: high-residue diet B: low-sodium diet C: regular diet D: high-protein diet

C: regular diet Explanation: 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.

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next week: A: the client will develop preeclampsia. B: the fetus will develop mature lungs. C: the client will not develop preterm labor. D: the fetus will not develop gestational diabetes.

C: the client will not develop preterm labor. Explanation: The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks' gestation indicates there is less than 1% risk of developing preterm labor in the next week. Fetal fibronectin is an extra cellular protein normally found in fetal membranes and deciduas and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes.

The primary care provider prescribes 5% dextrose in Ringer's solution and magnesium sulfate intravenously for an adolescent client with preeclampsia. Before administering the magnesium sulfate, what is the most important assessment the nurse should make? A: fetal heart rate variability B: maternal urinary output C: fetal position D: maternal respiratory rate

D: maternal respiratory rate Explanation: Magnesium sulfate is a central nervous system depressant used as an anticonvulsant for severe preeclampsia. It may depress respirations to a dangerously low and even life-threatening level. Therefore, the nurse must assess the client's respiratory rate before administering the drug. If the client's respiratory rate is below 12 breaths/minute, the primary care provider should be notified and the drug should be withheld. Although fetal heart rate variability is an important assessment, it is not the priority assessment in this situation. Fetal heart rate variability would be a priority assessment if the umbilical cord becomes compressed. Although maternal urinary output is an important assessment, it is not the priority assessment in this situation. Assessing maternal urinary output would be a priority after administering magnesium sulfate. Although fetal position, determined by Leopold's maneuvers, is an important assessment, it is not the priority assessment in this situation.

At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a cesarean birth. The nurse explains to the client that childbirth helps to prevent which complication? A: neonatal hyperbilirubinemia B: congenital anomalies C: perinatal asphyxia D: stillbirth

D: stillbirth Explanation: Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as a result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a cesarean section is necessary. Induction and cesarean section do not prevent neonatal hyperbilirubinemia, congenital anomalies, or perinatal asphyxia.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last? All options must be used. 1 Call for immediate assistance. 2 Turn the client to her side. 3 Maintain airway. 4 Assess for ruptured membranes.

1: Call for immediate assistance. 2: Turn the client to her side. 3: Maintain airway. 4: Assess for ruptured membranes. Explanation: 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. Next, the nurse should turn the client to her side and then maintain the airway by keeping the neck hyperextended. When the seizure is over, the nurse should assess the client for ruptured membranes and the fetal status.

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply. A: temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min B: urinary output less than 30 mL/h C: fetal heart rate with late decelerations D: blood pressure less than 140/90 mm Hg E: deep tendon reflexes 2+ F: magnesium level = 5.6 mg/dL (2.8 mmol/L)

A: temperature, 98° F (36.7° C); pulse, 72 beats/min; respiratory rate, 14 breaths/min E: deep tendon reflexes 2+ F: magnesium level = 5.6 mg/dL (2.8 mmol/L) Explanation: 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. The primary goal of magnesium sulfate therapy is to prevent seizures. 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. While extreme elevations of blood pressure must be treated, achieving a normal pressure carries the risk of decreasing perfusion to the fetus. 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.

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. A: Reassure the client that headaches are a normal part of pregnancy. B: Assess the client for vision changes or epigastric pain. C: Obtain a nonstress test. D: Assess the client's reflexes and presence of clonus. E: Determine if the client has a documented ultrasound for this pregnancy.

B: Assess the client for vision changes or epigastric pain. C: Obtain a nonstress test. D: Assess the client's reflexes and presence of clonus. Explanation: Headaches could be a sign of preeclampsia or eclamplsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyperreflexes, and clonus. Her fetus should be assessed using a nonstress test. An ultrasound in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia.

When caring for a client with preeclampsia, which action is a priority? A: Monitoring the client's labor carefully and preparing for a fast delivery B: Continually assessing the fetal tracing for signs of fetal distress C: Checking vital signs every 15 minutes to watch for increasing blood pressure D: Reducing visual and auditory stimulation

D: Reducing visual and auditory stimulation Explanation: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although monitoring the client's labor, preparing for a fast delivery, assessing the fetal tracing, and checking vital signs are important actions, they're lower priorities than reducing stimulation.

The nurse assessing a multigravida at 36 weeks' gestation plans to assess the client for symptoms of preeclampsia. The nurse determines the highest priority assessment would be of the client's: A: Face. B: Reflexes. C: Pulse. D: Ankles.

A: Face. Explanation: The most consistent signs of preeclampsia are sudden, excessive weight gain and facial and finger edema. Reflexes of 3+ to 4+ confirm a diagnosis of preeclampsia; however, such a result on its own will not necessarily suggest this condition. Checking the client's pulse will not give information relevant to preeclampsia. Ankle and leg edema is common in pregnant women due to the fluid volume shifts associated with pregnancy. Therefore, it is not a reliable indicator of preeclampsia.

At an obstetrics and gynecology physician's office, a nurse and a nursing student discuss the prioritization of returning client phone messages. Which of the following clients would be a priority to call? Select all that apply. A: A client at 34 weeks reporting transient blurred vision and shoulder pain B: A client at 32 weeks reporting a weight gain of 2 pounds (1 kg) over the last week C: A client at 36 weeks reporting feeling anxious and short of breath D: A client at 30 weeks reporting her morning sickness has suddenly returned E: A client with spotting and cramping 1 day after a cerclage

A: A client at 34 weeks reporting transient blurred vision and shoulder pain C: A client at 36 weeks reporting feeling anxious and short of breath D: A client at 30 weeks reporting her morning sickness has suddenly returned Explanation: Symptoms of preeclampsia include hypertension, proteinuria, edema, headache, abdominal pain/shoulder pain, lower back pain, sudden weight gain, and changes in vision. Clients could also report increased anxiety and sense of impending doom. These clients should come to the office and be assessed for preeclampsia. The client with the 2-pound (1 kg) weight gain over the last week would be an expected finding. Feeling cramping and spotting the day after a cerclage would also be an expected finding. "Morning sickness" should resolve after the first trimester, and a sudden return later in the pregnancy could be a symptom of preeclampsia.

A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe preeclampsia. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which action should the nurse do first? A: Pad the side rails of the client's bed. B: Turn the client to the right side. C: Insert a padded tongue blade into the client's mouth. D: Call for immediate assistance in the client's room.

D: Call for immediate assistance in the client's room. Explanation: The first action by the nurse should be to call for immediate assistance in the client's room because this is an emergency. Throughout the seizure, the nurse should note the time and length of the seizure and continue to monitor the status of both client and fetus. The side rails should have been padded at the time of the client's admission to the hospital as part of seizure precautions. The client should be turned to her left side to improve placental perfusion. Inserting a tongue blade is not recommended because it can further obstruct the airway or cause injury to the client's teeth.

A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her physician if she experiences which symptoms? Select all that apply. A: Headache. B: Increased urine output. C: Blurred vision. D: Difficulty sleeping. E: Epigastric pain. F: Severe nausea and vomiting.

A: Headache. B: Blurred vision. E: Epigastric pain. F: Severe nausea and vomiting. Explanation: Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms.

A 39-year-old multigravid client who is visiting the clinic at 14 weeks' gestation tells the nurse that she has had severe nausea and vomiting since becoming pregnant. The client's fundal measurement is 20 cm. The nurse should assess the client for signs and symptoms of which problem? A: molar pregnancy B: multifetal pregnancy C: increased fetal activity D: history of polycythemia

A: molar pregnancy Explanation: Severe nausea and vomiting that continue throughout the first trimester of pregnancy and into the second trimester in conjunction with the client's enlarged fundus for her gestational age may be indicative of a hydatidiform mole. A molar pregnancy, occurring more often in multigravid clients, is associated with early symptoms of preeclampsia and an enlarged fundus. An enlarged fundus may be associated with multifetal pregnancies but not with the client's symptoms of severe nausea and vomiting. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with increased fetal activity because there is no fetus. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with polycythemia.

As a nurse begins the shift on the obstetrical unit, there are several new admissions. The client with which condition would be a candidate for induction? A: preeclampsia B: active herpes C: face presentation D: fetus with late decelerations

A: preeclampsia Explanation: The client with preeclampsia would be a candidate for the induction process because ending the pregnancy is the only way to cure preeclampsia. A client with active herpes would be a candidate for a cesarean section to prevent the fetus from contracting the virus while passing through the birth canal. The woman with a face presentation will not be able to give birth vaginally due to the extended position of the neck. The client whose fetus exhibits late decelerations without oxytocin would be at greater risk for fetal distress with use of this drug. Late decelerations indicate the fetus does not have enough placental reserves to remain oxygenated during the entire contraction. This client may require a cesarean section.

A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which signs and symptoms? A: pregnancy-induced hypertension B: gestational diabetes C: hypothyroidism D: polycythemia

A: pregnancy-induced hypertension Explanation: Hydatidiform mole is suspected when the following are present: gestational hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies.

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client makes which statement? A: "I may develop hyperthyroidism because of my high blood pressure." B: "I need close monitoring because I may have a small-for-gestational-age infant." C: "It is possible that I will have excess amniotic fluid and may need a cesarean section." D: "I may develop placenta accreta, so I need to keep my clinic appointments."

B: "I need close monitoring because I may have a small-for-gestational-age infant." Explanation: Women with chronic hypertension during pregnancy are at risk for complications such as preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a small-for-gestational-age infant. There is no association between chronic hypertension and hyperthyroidism. Pregnant women with chronic hypertension are not at an increased risk for hydramnios (polyhydramnios), an abnormally large amount of amniotic fluid. Clients with diabetes and multiple gestations are at risk for this condition. Placenta accreta, a rare placental abnormality, refers to a condition in which the placenta abnormally adheres to the uterine lining. It is not associated with chronic hypertension.

A client is receiving I.V. magnesium sulfate for severe preeclampsia. The nurse should monitor for: A: anemia. B: decreased urine output. C: hyperreflexia. D: increased respiratory rate.

B: decreased urine output. Explanation: Decreased urine output is a potential adverse effect of magnesium sulfate. If output decreases, the drug may accumulate to toxic levels. Urine output should be maintained at a rate of 30 ml/hour. Anemia isn't associated with magnesium sulfate therapy. Magnesium infusions may cause depression of deep tendon reflexes or hyporeflexia, not hyperreflexia. The client should be monitored for respiratory depression (not an increased respiratory rate) and paralysis when serum magnesium levels reach about 15 mEq/L.