A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding concerns her nurse? a. Blood pressure (BP) increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. A dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day - ANS: C 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 made. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or 15 mm Hg diastolic pressure. 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, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician because the lab results are indicative of: a. Eclampsia b. Disseminated intravascular coagulation (DIC) c. HELLP syndrome d. Idiopathic thrombocytopenia - ANS: C HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). Eclampsia is determined by the presence of seizures. A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to a. Insert an oral airway b. Suction the mouth to prevent aspiration c. Administer oxygen by mask d. Stay with the client and call for help - ANS: D If a client becomes eclamptic, 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. 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/min, respiratory rate 10 breaths/min, blood pressure (BP) 148/90 mm Hg, absent deep tendon reflexes, and no ankle clonus. The client complains, "I'm so thirsty and warm." The nurse a. Calls for a stat magnesium sulfate level b. Administers oxygen c. Discontinues the magnesium sulfate infusion d. Prepares to administer hydralazine - ANS: C The client is displaying clinical signs and symptoms of magnesium toxicity. Magnesium should be discontinued immediately. Additionally, calcium gluconate, the antidote for magnesium, may be administered. 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. The nurse suspects the onset of: a. Eclamptic seizure b. Rupture of the uterus c. Placenta previa d. Abruptio placentae - ANS: D Uterine tenderness in the presence of increasing tone may be the earliest finding of abruptio placentae. Women with preeclampsia are at increased risk for an abruption due to decreased placental perfusion. Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia and, in many cases, 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. The nurse determines that the couple needs further information when the woman's husband says 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." - ANS: C 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. Your client has been on magnesium sulfate for 20 hours for treatment of preeclampsia. She just delivered a viable infant girl 30 minutes ago. What uterine findings do you expect to observe or assess in this client? a. Absence of uterine bleeding in the postpartum period b. A fundus firm below the level of the umbilicus c. Scant lochia flow d. A boggy uterus with heavy lochia flow - ANS: D High serum levels of magnesium can cause relaxation of smooth muscle such as the uterus. Because of this tocolytic effect, the client most likely will have a boggy uterus with increased amounts of bleeding. All women experience uterine bleeding in the postpartum period, especially those that have received magnesium therapy. Due to the tocolytic effects of magnesium sulfate, this client most likely will have a boggy uterus. Your client is being induced because of her 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 it taking so long?" The most appropriate response by the nurse is 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." - ANS: A