Question 1

A woman with preeclampsia has a seizure.What is the nurse's highest priority during a seizure?&#10;A) To insert an oral airway&#10;B) To suction the mouth to prevent aspiration&#10;C) To administer oxygen by mask&#10;D) To stay with the client and call for help

Accepted Answer

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.

Question 2

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

Accepted Answer

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.

Question 3

A primigravida is being monitored at the prenatal clinic for preeclampsia.Which finding is of greatest concern to the nurse?&#10;A) Blood pressure (BP) increase to 138/86 mm Hg&#10;B) Weight gain of 0.5 kg during the past 2 weeks&#10;C) Dipstick value of 3+ for protein in her urine&#10;D) Pitting pedal edema at the end of the day

Accepted Answer

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.

Question 4

Which statement most accurately describes the HELLP syndrome?&#10;A) Mild form of preeclampsia&#10;B) Diagnosed by a nurse alert to its symptoms&#10;C) Characterized by hemolysis, elevated liver enzymes, and low platelets&#10;D) Associated with preterm labor but not perinatal mortality

Accepted Answer

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.

Question 5

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?&#10;A) Sleepy, sedated affect&#10;B) Respiratory rate of 10 breaths per minute&#10;C) DTRs of 2&#10;D) Absent ankle clonus

Accepted Answer

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.

Question 6

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."

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Accepted Answer

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.

Question 7

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?

A) Eclampsia
B) Disseminated intravascular coagulation (DIC) syndrome
C) Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome
D) Idiopathic thrombocytopenia

Accepted Answer

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.

Question 8

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?&#10;A) Sluggish or diminished&#10;B) Brisk, hyperactive, with intermittent or transient clonus&#10;C) Active or expected response&#10;D) More brisk than expected, slightly hyperactive

Accepted Answer

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.

Question 9

Which neonatal complications are associated with hypertension in the mother?&#10;A) Intrauterine growth restriction (IUGR) and prematurity&#10;B) Seizures and cerebral hemorrhage&#10;C) Hepatic or renal dysfunction&#10;D) Placental abruption and DIC

Accepted Answer

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.

Question 10

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?

A) Thrombophlebitis
B) Psychologic stress
C) Fluid retention
D) Cardiovascular deconditioning

Accepted Answer

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.

Question 11

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."

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Accepted Answer

The answer of A woman with worsening preeclampsia is admitted...

Question 12

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

Accepted Answer

The answer of A woman at 39 weeks of gestation...

Question 13

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

Accepted Answer

The answer of A pregnant woman has been receiving a...

Question 14

Which statement best describes chronic hypertension?&#10;A) Chronic hypertension is defined as hypertension that begins during pregnancy and lasts for the duration of the pregnancy.&#10;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.&#10;C) Chronic hypertension is general hypertension plus proteinuria.&#10;D) Chronic hypertension can occur independently of or simultaneously with preeclampsia.

Accepted Answer

The answer of Which statement best describes chronic hypertension?&#10;A) Chronic...

Question 15

Which intervention is most important when planning care for a client with severe gestational hypertension?&#10;A) Induction of labor is likely, as near term as possible.&#10;B) If at home, the woman should be confined to her bed, even with mild gestational hypertension.&#10;C) Special diet low in protein and salt should be initiated.&#10;D) Vaginal birth is still an option, even in severe cases.

Accepted Answer

The answer of Which intervention is most important when planning...

Question 16

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?

A) Hydralazine
B) Magnesium sulfate bolus
C) Diazepam
D) Calcium gluconate

Accepted Answer

The answer of A woman with severe preeclampsia has been...

Question 17

What is the primary purpose for magnesium sulfate administration for clients with preeclampsia and eclampsia?&#10;A) To improve patellar reflexes and increase respiratory efficiency&#10;B) To shorten the duration of labor&#10;C) To prevent convulsions&#10;D) To prevent a boggy uterus and lessen lochial flow

Accepted Answer

The answer of What is the primary purpose for magnesium...

Question 18

What is the most common medical complication of pregnancy?&#10;A) Hypertension&#10;B) Hyperemesis gravidarum&#10;C) Hemorrhagic complications&#10;D) Infections

Accepted Answer

The answer of What is the most common medical complication...

Question 19

What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?&#10;A) Risk for injury to mother and fetus, related to central nervous system (CNS) irritability&#10;B) Risk for altered gas exchange&#10;C) Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate&#10;D) Risk for increased cardiac output, related to the use of antihypertensive drugs

Accepted Answer

The answer of What nursing diagnosis is the most appropriate...

Question 20

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

Accepted Answer

The answer of The client has been on magnesium sulfate...

Question 21

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?

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.

Accepted Answer

The answer of One of the most important components of...

Question 22

Which adverse prenatal outcomes are associated with the HELLP syndrome?&#10;A) Placental abruption&#10;B) Placenta previa&#10;C) Renal failure&#10;D) Cirrhosis&#10;E) Maternal and fetal death

Accepted Answer

The answer of Which adverse prenatal outcomes are associated with...

Deck 27: Hypertensive Disorders