Question 1

Which statement most accurately describes the HELLP syndrome?

Accepted Answer

The HELLP syndrome is characterized by hemolysis (breakdown of red blood cells), elevated liver enzymes, and low platelets. It is a serious complication of pregnancy, often associated with preeclampsia. It can be life-threatening for both the mother and baby, with increased risk of perinatal mortality. Diagnosis may require a healthcare provider well-versed with its symptoms, but not necessarily only a nurse.

Question 2

A woman experiencing 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?

Accepted Answer

The client's blood pressure is still significantly elevated, indicating incomplete management of the preeclampsia. Hydralazine is a medication commonly used to treat hypertension in preeclampsia. Magnesium sulfate bolus would not be indicated as the client is already receiving a continuous infusion. Diazepam would not be indicated for hypertension. Calcium gluconate is an antidote for magnesium toxicity and would not be indicated based on the assessment findings provided.

Question 3

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?

Accepted Answer

A respiratory rate of 10 breaths per minute could indicate respiratory depression, which is a potential side effect of magnesium sulfate toxicity. The other findings, including a sleepy/sedated affect, DTRs of 2+, and absent ankle clonus, are expected or common findings with magnesium sulfate administration.

Question 4

A primigravida is being monitored at the prenatal clinic for preeclampsia.Which finding is of greatest concern to the nurse?

Accepted Answer

A dipstick value of 3+ for protein in the urine is indicative of significant proteinuria, which is a hallmark sign of preeclampsia. This finding is of greatest concern as it indicates potential damage to the kidneys and other organs, placing the mother and the fetus at risk for serious complications such as seizures, stroke, and fetal distress. The increase in BP is cause for concern, but not as significant as the proteinuria. Weight gain and edema are common in pregnancy and not directly related to preeclampsia, although excessive weight gain and severe edema may be potential signs of preeclampsia.

Question 5

Which statement best describes chronic hypertension?

Accepted Answer

Chronic hypertension is a long-term condition that can exist prior to pregnancy or be diagnosed before 20 weeks of gestation and persist beyond pregnancy. It can occur independently of pregnancy-related conditions like preeclampsia but can also coexist with them, differentiating it from options A, B, and C which describe conditions or thresholds specific to pregnancy-induced hypertension or preeclampsia.

Question 6

The nurse has evaluated a client with preeclampsia by assessing deep tendon reflexes (DTRs).The result is a grade of 3+.Which DTR response most accurately describes this score?

Accepted Answer

A grade of 3+ for deep tendon reflexes indicates that the reflexes are more brisk than expected and slightly hyperactive, which is consistent with option D.

Question 7

Which adverse prenatal outcomes are associated with the HELLP syndrome? (Select all that apply. )

Accepted Answer

HELLP syndrome is associated with several adverse prenatal outcomes, including placental abruption, renal failure, and maternal and fetal death. Placenta previa and cirrhosis are not typically associated with HELLP syndrome.

Question 8

Which neonatal complications are associated with hypertension in the mother?

Accepted Answer

Hypertension in the mother increases the risk of intrauterine growth restriction (IUGR) and premature delivery, which can lead to complications in the neonate. Seizures, cerebral hemorrhage, hepatic or renal dysfunction, placental abruption, and DIC are also potential complications of hypertension in the mother, but they are not specifically associated with neonatal outcomes.

Question 9

What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

Accepted Answer

Severe preeclampsia can lead to CNS irritability and potential seizures, which puts both the mother and fetus at risk for injury. This diagnosis reflects the potential for harm and guides nursing interventions to prevent injury. The other options are not as relevant to severe preeclampsia.

Question 10

Which intervention is most important when planning care for a client with severe gestational hypertension?

Accepted Answer

Induction of labor is the most important intervention in severe gestational hypertension, as delivery is the only cure for the condition. Delaying delivery can lead to complications such as eclampsia or placental abruption, which can be life-threatening for both the mother and the baby. Therefore, delivery should take place as soon as possible, preferably at term, to ensure the best possible outcome for both.

Question 11

One of the most important components of the physical assessment of the pregnant client is the determination of blood pressure (BP).Which techniques are important in obtaining accurate BP readings? (Select all that apply. )

Accepted Answer

It is important for the client to be seated and for the arm to be placed at the level of the heart to obtain accurate BP readings. An electronic BP device may be used, but it is recommended to also take manual readings for comparison. The cuff should cover a minimum of 80% of the upper arm, not 60%. Using the same arm for every reading helps ensure consistency in measurements.

Question 12

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?

Accepted Answer

Magnesium sulfate is known to inhibit the action of oxytocin, making it less effective in inducing and stimulating labor. This can lead to a longer labor process, and the nurse should explain this to the client in a clear and understandable manner. Option B is not an appropriate response as it does not provide any helpful information. Option C is a general statement and does not address the client's specific concern. Option D is unprofessional and dismissive of the client's question.

Question 13

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 partner.Which statement by the partner leads the nurse to believe that the couple needs further information?

Accepted Answer

Bringing a toddler to visit may not be appropriate during the woman's labor and delivery, as it can be disruptive and distracting for the couple. The nurse may need to provide further information and guidelines about appropriate visitors and support during labor. The other statements show understanding and readiness for labor and delivery.

Question 14

What is the most common medical complication of pregnancy?

Accepted Answer

Hypertension, also known as high blood pressure, is the most common medical complication of pregnancy, affecting up to 10% of pregnancies. It can lead to complications such as preeclampsia, preterm labor, and fetal growth restriction. Hyperemesis gravidarum (severe nausea and vomiting during pregnancy), hemorrhagic complications (excessive bleeding), and infections are also potential complications of pregnancy, but they are less common than hypertension.

Question 15

The labor of a pregnant woman with preeclampsia is going to be induced.Before initiating the oxytocin 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?

Accepted Answer

The laboratory findings in this scenario are indicative of HELLP syndrome. The platelet count is low, the AST level is elevated, and the hematocrit is falling. These are common findings in HELLP syndrome, which is a severe form of preeclampsia. Eclampsia may develop if the condition progresses but is not indicated in these lab findings alone. DIC syndrome and idiopathic thrombocytopenia may also present with low platelet counts, but the elevated AST level and falling hematocrit are more indicative of HELLP syndrome.

Question 16

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?

Accepted Answer

The symptoms described suggest placental abruption, which is a potentially life-threatening complication of pregnancy associated with preeclampsia. Eclamptic seizures would typically be preceded by signs of severe preeclampsia, such as high blood pressure and proteinuria. Rupture of the uterus and placenta previa may also cause vaginal bleeding, but the sudden increase in contraction frequency and a tense, painful abdomen are not typical with either of these conditions.

Question 17

Which client exhibits the greatest number of risk factors associated with the development of preeclampsia?

Accepted Answer

C) The 19-year-old African American who is pregnant with twins exhibits the greatest number of risk factors for preeclampsia, including being of African American descent, a high-risk ethnicity for this condition, and carrying a multiple gestation, which increases the risk of preeclampsia. Age, while a factor, is less significant in this context compared to the other listed risk factors.

Question 18

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?

Accepted Answer

The client is exhibiting signs of magnesium toxicity, including absent DTRs and a slowed respiratory rate. Discontinuation of the magnesium sulfate infusion is the immediate priority to prevent further toxicity. The nurse should also encourage the client to drink water to alleviate thirst. Administering oxygen and preparing to administer hydralazine are not appropriate actions at this time. A magnesium sulfate level may be ordered later, but it is not the immediate priority.

Question 19

A woman with preeclampsia has a seizure.What is the nurse's highest priority during a seizure?

Accepted Answer

During a seizure, the highest priority of the nurse is to stay with the client and call for help. The nurse should make sure that the client does not fall off the bed or hurt themselves, and then call for assistance. Administering oxygen or suctioning may be necessary after the seizure but staying with the client and calling for help is the priority during the seizure. An oral airway should not be inserted during a seizure as it may cause the client to gag or aspirate.

Quiz 27: Hypertensive Disorders