Flashcards in Chapter 27 Deck (32):
1. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. Dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ alerts the nurse that additional testing or assessment should be performed. A 24-hour urine collection is preferred over dipstick testing attributable to accuracy. Generally, hypertension is defined as a BP of 140/90 mm Hg or an increase in systolic pressure of 30 mm Hg or diastolic pressure of 15 mm Hg. Preeclampsia may be demonstrated as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many normal pregnancies, as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.
2. The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the woman’s latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level, and a falling hematocrit. The laboratory results are indicative of which condition?
b. Disseminated intravascular coagulation (DIC) syndrome
c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome
d. Idiopathic thrombocytopenia
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver (EL) enzymes, and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is the presence of low platelets of unknown cause and is not associated with preeclampsia.
3. A woman with preeclampsia has a seizure. What is the nurse’s highest priority during a seizure?
a. To insert an oral airway
b. To suction the mouth to prevent aspiration
c. To administer oxygen by mask
d. To stay with the client and call for help
If a client becomes eclamptic, then the nurse should stay with the client and call for help. Nursing actions during a convulsion are directed toward ensuring a patent airway and client safety. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the client’s head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the client’s mouth. Oxygen is administered after the convulsion has ended.
4. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute, BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client complains, “I’m so thirsty and warm.” What is the nurse’s immediate action?
a. To call for an immediate magnesium sulfate level
b. To administer oxygen
c. To discontinue the magnesium sulfate infusion
d. To prepare to administer hydralazine
Regardless of the magnesium level, the client is displaying the clinical signs and symptoms of magnesium toxicity. The first action by the nurse should be to discontinue the infusion of magnesium sulfate. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension in severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than 160 mm Hg or a diastolic BP higher than 110 mm Hg.
5. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, dark red vaginal bleeding, and a tense, painful abdomen. Which clinical change does the nurse anticipate?
a. Eclamptic seizure
b. Rupture of the uterus
c. Placenta previa
d. Abruptio placentae
Uterine tenderness in the presence of increasing tone may be the earliest sign of abruptio placentae. Women with preeclampsia are at increased risk for an abruption attributable to decreased placental perfusion. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture exhibits hypotonic uterine activity, signs of hypovolemia, and, in many cases, the absence of pain. Placenta previa exhibits bright red, painless vaginal bleeding.
6. A woman with worsening preeclampsia is admitted to the hospital’s labor and birth unit. The physician explains the plan of care for severe preeclampsia, including the induction of labor, to the woman and her husband. Which statement by the husband leads the nurse to believe that the couple needs further information?
a. “I will help my wife use the breathing techniques that we learned in our childbirth classes.”
b. “I will give my wife ice chips to eat during labor.”
c. “Since we will be here for a while, I will call my mother so she can bring the two boys—2 years and 4 years of age—to visit their mother.”
d. “I will stay with my wife during her labor, just as we planned.”
Arranging a visit with their two children indicates that the husband does not understand the importance of the quiet, subdued environment that is needed to prevent his wife’s condition from worsening. Implementing breathing techniques is indicative of adequate knowledge related to pain management during labor. Administering ice chips indicates an understanding of nutritional needs during labor. Staying with his wife during labor demonstrates the husband’s support for his wife and is appropriate.
7. The client has been on magnesium sulfate for 20 hours for the treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings does the nurse expect to observe or assess in this client?
a. Absence of uterine bleeding in the postpartum period
b. Fundus firm below the level of the umbilicus
c. Scant lochia flow
d. Boggy uterus with heavy lochia flow
High serum levels of magnesium can cause a relaxation of smooth muscle such as the uterus. Because of this tocolytic effect, the client will most likely have a boggy uterus with increased amounts of bleeding. All women experience uterine bleeding in the postpartum period, especially those who have received magnesium therapy. Rather than scant lochial flow, however, this client will most likely have a heavy flow attributable to the relaxation of the uterine wall caused by magnesium administration.
8. The client is being induced in response to worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active, despite several hours of oxytocin administration. She asks the nurse, “Why is this taking so long?” What is the nurse’s most appropriate response?
a. “The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.”
b. “I don’t know why it is taking so long.”
c. “The length of labor varies for different women.”
d. “Your baby is just being stubborn.”
Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor. The amount of oxytocin needed to stimulate labor may be more than that needed for the woman who is not receiving magnesium sulfate. The nurse should explain to the client the effects of magnesium sulfate on the duration of labor. Although the length of labor varies for different women, the most likely reason this woman’s labor is protracted is the tocolytic effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of labor.
9. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?
a. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability
b. Risk for altered gas exchange
c. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate
d. Risk for increased cardiac output, related to the use of antihypertensive drugs
Risk for injury is the most appropriate nursing diagnosis for this client scenario. Gas exchange is more likely to become impaired, attributable to pulmonary edema. A risk for excess, not deficient, fluid volume, related to increased sodium retention, is increased, and a risk for decreased, not increased, cardiac output, related to the use of antihypertensive drugs, also is increased.
10. Which statement best describes chronic hypertension?
a. Chronic hypertension is defined as hypertension that begins during pregnancy and lasts for the duration of the pregnancy.
b. Chronic hypertension is considered severe when the systolic BP is higher than 140 mm Hg or the diastolic BP is higher than 90 mm Hg.
c. Chronic hypertension is general hypertension plus proteinuria.
d. Chronic hypertension can occur independently of or simultaneously with preeclampsia.
Women with chronic hypertension may develop superimposed preeclampsia, which increases the morbidity for both the mother and the fetus. Chronic hypertension is present before pregnancy or diagnosed before the 20 weeks of gestation and persists longer than 6 weeks postpartum. Chronic hypertension becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an excessive concentration of protein in the urine and is a complication of hypertension, not a defining characteristic.
11. Which intervention is most important when planning care for a client with severe gestational hypertension?
a. Induction of labor is likely, as near term as possible.
b. If at home, the woman should be confined to her bed, even with mild gestational hypertension.
c. Special diet low in protein and salt should be initiated.
d. Vaginal birth is still an option, even in severe cases.
By 34 weeks of gestation, the risk of continuing the pregnancy may be considered greater than the risks of a preterm birth. Strict bed rest is controversial for mild cases; some women in the hospital are even allowed to move around. Diet and fluid recommendations are essentially the same as for healthy pregnant women, although some authorities have suggested a diet high in protein. Women with severe gestational hypertension should expect a cesarean delivery.
12. What is the primary purpose for magnesium sulfate administration for clients with preeclampsia and eclampsia?
a. To improve patellar reflexes and increase respiratory efficiency
b. To shorten the duration of labor
c. To prevent convulsions
d. To prevent a boggy uterus and lessen lochial flow
Magnesium sulfate is the drug of choice used to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can also increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.
13. The American College of Obstetricians and Gynecologists (ACOG) has developed a comprehensive list of risk factors associated with the development of preeclampsia. Which client exhibits the greatest number of these risk factors?
a. 30-year-old obese Caucasian with her third pregnancy
b. 41-year-old Caucasian primigravida
c. 19-year-old African American who is pregnant with twins
d. 25-year-old Asian American whose pregnancy is the result of donor insemination
Three risk factors are present in the 19-year-old African-American client. She has African-American ethnicity, is at the young end of the age distribution, and has a multiple pregnancy. In planning care for this client, the nurse must frequently monitor her BP and teach her to recognize the early warning signs of preeclampsia. The 30-year-old obese Caucasian client has only has one known risk factor: obesity. Age distribution appears to be U-shaped, with women younger than 20 years of age and women older than 40 years of age being at greatest risk. Preeclampsia continues to be more frequently observed in primigravidas; this client is a multigravida woman. Two risk factors are present for the 41-year-old Caucasian primigravida client. Her age and status as a primigravida place her at increased risk for preeclampsia. Caucasian women are at a lower risk than are African-American women. The 25-year-old Asian-American client exhibits only one risk factor. Pregnancies that result from donor insemination, oocyte donation, and embryo donation are at an increased risk of developing preeclampsia.
14. Women with mild gestational hypertension and mild preeclampsia can be safely managed at home with frequent maternal and fetal evaluation. Complete or partial bed rest is still frequently ordered by some providers. Which complication is rarely the result of prolonged bed rest?
b. Psychologic stress
c. Fluid retention
d. Cardiovascular deconditioning
No evidence has been found that supports the practice of bed rest to improve pregnancy outcome. Fluid retention is not an adverse outcome of prolonged bed rest. The woman is more likely to experience diuresis with accompanying fluid and electrolyte imbalance and weight loss. Prolonged bed rest is known to increase the risk for thrombophlebitis. Psychologic stress is known to begin on the first day of bed rest and continue for the duration of the therapy. Therefore, restricted activity, rather than complete bed rest, is recommended. Cardiovascular deconditioning is a known complication of bed rest.
15. Which neonatal complications are associated with hypertension in the mother?
a. Intrauterine growth restriction (IUGR) and prematurity
b. Seizures and cerebral hemorrhage
c. Hepatic or renal dysfunction
d. Placental abruption and DIC
Neonatal complications are related to placental insufficiency and include IUGR, prematurity, and necrotizing enterocolitis. Seizures and cerebral hemorrhage are maternal complications. Hepatic and renal dysfunction are maternal complications of hypertensive disorders in pregnancy. Placental abruption and DIC are conditions related to maternal morbidity and mortality.
16. The nurse has evaluated a client with preeclampsia by assessing DTRs. The result is a grade of 3+. Which DTR response most accurately describes this score?
a. Sluggish or diminished
b. Brisk, hyperactive, with intermittent or transient clonus
c. Active or expected response
d. More brisk than expected, slightly hyperactive
DTRs reflect the balance between the cerebral cortex and the spinal cord. They are evaluated at baseline and to detect changes. A slightly hyperactive and brisk response indicates a grade 3+ response.
17. A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the client and documents the following findings: temperature of 37.1° C, pulse rate of 96 beats per minute, respiratory rate of 24 breaths per minute, BP of 155/112 mm Hg, 3+ DTRs, and no ankle clonus. The nurse calls the provider with an update. The nurse should anticipate an order for which medication?
b. Magnesium sulfate bolus
d. Calcium gluconate
Hydralazine is an antihypertensive medication commonly used to treat hypertension in severe preeclampsia. Typically, it is administered for a systolic BP higher than 160 mm Hg or a diastolic BP higher than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of CNS irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam is sometimes used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.
18. The client being cared for has severe preeclampsia and is receiving a magnesium sulfate infusion. Which new finding would give the nurse cause for concern?
a. Sleepy, sedated affect
b. Respiratory rate of 10 breaths per minute
c. DTRs of 2
d. Absent ankle clonus
A respiratory rate of 10 breaths per minute indicates the client is experiencing respiratory depression from magnesium toxicity. Because magnesium sulfate is a CNS depressant, the client will most likely become sedated when the infusion is initiated. DTRs of 2 and absent ankle clonus are normal findings.
19. What is the most common medical complication of pregnancy?
b. Hyperemesis gravidarum
c. Hemorrhagic complications
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of pregnant women will have nausea and vomiting, but a relatively few will have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy; hypertension is the most common. Infection is a risk factor for preeclampsia.
20. Which statement most accurately describes the HELLP syndrome?
a. Mild form of preeclampsia
b. Diagnosed by a nurse alert to its symptoms
c. Characterized by hemolysis, elevated liver enzymes, and low platelets
d. Associated with preterm labor but not perinatal mortality
The acronym HELLP stands for hemolysis (H), elevated liver (EL) enzymes, and low platelets (LP). The HELLP syndrome is a variant of severe preeclampsia and is difficult to identify because the symptoms are not often obvious. The HELLP syndrome must be diagnosed in the laboratory. Preterm labor is greatly increased; therefore, so is perinatal mortality.
1. Which adverse prenatal outcomes are associated with the HELLP syndrome? (Select all that apply.)
a. Placental abruption
b. Placenta previa
c. Renal failure
e. Maternal and fetal death
ANS: A, C, E
The HELLP syndrome is associated with an increased risk for adverse perinatal outcomes, including placental abruption, acute renal failure, subcapsular hepatic hematoma, hepatic rupture, recurrent preeclampsia, preterm birth, and fetal and maternal death. The HELLP syndrome is associated with an increased risk for placental abruption, not placenta previa. It is also associated with an increased risk for hepatic hematoma, not cirrhosis.
2. One of the most important components of the physical assessment of the pregnant client is the determination of BP. Consistency in measurement techniques must be maintained to ensure that the nuances in the variations of the BP readings are not the result of provider error. Which techniques are important in obtaining accurate BP readings? (Select all that apply.)
a. The client should be seated.
b. The client’s arm should be placed at the level of the heart.
c. An electronic BP device should be used.
d. The cuff should cover a minimum of 60% of the upper arm.
e. The same arm should be used for every reading.
ANS: A, B, E
BP readings are easily affected by maternal position. Ideally, the client should be seated. An alternative position is left lateral recumbent with the arm at the level of the heart. The arm should always be held in a horizontal position at approximately the level of the heart. The same arm should be used at every visit. The manual sphygmomanometer is the most accurate device. If manual and electronic devices are used in the care setting, then the nurse must use caution when interpreting the readings. A proper size cuff should cover at least 80% of the upper arm or be approximately 1.5 times the length of the upper arm.
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 affect.
b. A respiratory rate of 10 breaths/min.
c. Deep tendon reflexes of 2+.
d. Absence of ankle clonus.
A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. Deep tendon reflexes of 2+ are a normal finding, as is absence of ankle clonus.
A nurse caring for pregnant women must be aware that the most common medical complication of pregnancy is:
b. Hyperemesis gravidarum.
c. Hemorrhagic complications.
Preeclampsia and eclampsia are two noted, deadly forms of hypertension, which is the most common medical complication of pregnancy. A large percentage of pregnant women have nausea and vomiting, but a relative few have the severe form called hyperemesis gravidarum. Hemorrhagic complications are the second most common medical complication of pregnancy.
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. Severe preeclampsia is defined as preeclampsia plus proteinuria.
Vasospasms diminish the diameter of blood vessels, which impedes blood flow to all organs. Preeclampsia occurs after week 20 of gestation and can run the duration of the pregnancy. The causes of preeclampsia and eclampsia are unknown, although several have been suggested. Preeclampsia includes proteinuria; severe cases are characterized by greater proteinuria or any of nine other conditions.
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.
Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. A temporary decrease in blood pressure can occur but is not the purpose of administering this medication. 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. Diuresis is not an expected outcome of magnesium sulfate administration.
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:
b. Magnesium sulfate bolus.
d. Calcium gluconate.
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.
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.
The acronym HELLP stands for hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). HELLP syndrome is a variant of severe preeclampsia. It is difficult to identify, because the symptoms often are not obvious. It must be diagnosed in the laboratory. Preterm labor is greatly increased with HELLP syndrome, and so is perinatal mortality.
A pregnant woman who is at 18 weeks of gestation has an elevated blood pressure of 140/98. Past medical history reveals that the woman has been treated for hypertension. On the basis of this information, the nurse would classify this patient as having:
b. Gestational hypertension.
c. Superimposed preeclampsia.
d. Chronic hypertension.
Because this patient already has a medical history of hypertension and is now exhibiting hypertension prior to the 20th week of gestation, she would be considered to have superimposed preeclampsia. Preeclampsia would be the classification in a patient without a history of hypertension who was hypertensive following the 20th week of pregnancy. Gestational hypertension occurs after the 20th week of pregnancy in a patient who was previously normotensive. Even though the patient has chronic hypertension, the fact that she is now pregnant determines that she would be classified as having superimposed preeclampsia.
A nurse is monitoring a patient’s reflexes (DTRs) while receiving magnesium sulfate therapy for treatment of preeclampsia. Which assessment finding indicates a cause for concern?
a. Bilateral DTRs noted at 2+
b. DTRs response has been noted at 1+ since onset of therapy
c. Positive clonus response elicited unilaterally
d. Patient reports no pain upon examination of DTRs by nurse
Positive clonus response elicited unilaterally is a cause for concern as it suggests a hyperactive response. Typically, there is no pain associated with determination of DTRs so this finding would be considered to be normal, as would bilateral DTRs noted at 2+.
Even though DTRs at 1+ indicate a sluggish or decreased response, this finding is unchanged since the initiation of therapy. The nurse would continue to monitor.
Which of the following antihypertensive medications would cause a pregnant woman to have a positive Coombs test result?
a. Nifedipine (Procardia)
b. Methyldopa (Aldomet)
c. Labetalol hydrochloride (Trandate)
d. Hydralazine (Apresoline)
A positive Coombs test result can occur in about 20% of patients taking methyldopa (Aldomet). None of the other drugs listed would have this effect.