Chapter 25: Complications of Pregnancy

Question 1

what are the 3 most common causes of hemorrhage during the first half of pregnancy?

Answer 1

• abortion
• ectopic pregnancy
• gestational trophoblastic dz

Question 2

abortion

Answer 2

• loss of pregnancy of less than 20 weeks or a fetus less than 500 g
• can be spontaneous or induced

Question 3

spontaneous abortion

Answer 3

• termination of pregnancy w/o action taken by the woman or another person
• incidence inc with paternal age and with inc maternal age
• most occur during first 12 weeks of pregnancy
• most common cause: severe congential abnormalities that are incompatible with life
  
  • also caused by syphilis, listeriosis, toxoplasmosis, brucellosis, rubela, intraabdominal infections
• 6 types:
  
  • threatened
  • inevitable
  • incomplete
  • complete
  • missed
  • recurrent

Question 4

threatened abortion

Answer 4

• first sign is vaginal bleeding
  
  • other S/S are uterine cramping, persistent backache, feelings of pelvic pressure
• mgmt:
  
  • bleeding during 1st half of pregnancy is considered a threatened abortion
  • report bleeding and given detailed hx about bleeding and other symptoms
  • U/S exam is done and test hCG levels
  • should limit sexual activity until bleeding as ceased
  • count perineal pads and note quantity/color

Question 5

what problems may result from a pregnancy that does not end in spontaneous abortion after early bleeding?

Answer 5

• prematurity
• SGA infant
• abnormal presentation
• perinatal asphyxia

Question 6

inevitable abortion

Answer 6

• ROM and cervix dilates
  
  • incomplete evacuation–>infection/sepsis
• mgmt:
  
  • natural expulsion is common
    
    • vacuum curettage: removal of uterine contents with vacuum–>clear uterus if natural process is not effective
    • D&C: used if pregnancy is more advanced or bleeding is excessive
      
      • involves stretching the cervical os to scrape/suction uterus

Question 7

incomplete abortion

Answer 7

• some but not all of products of conception are expelled
  
  • S/S: active uterine bleeding, severe abdominal cramping, cervix opened
• mgmt:
  
  • retained tissue prevents uterus from contracting firly, so profuse bleeding occurs
    
    • MUST first stabilize CV state
  • draw blood specimen for type and cross
  • insert IV for fluid replacement and drug administration
  • D&C done to remove tissue
    
    • D&E done if the pregnancy is more advanced w/ a larger amount of tissue
    • may need to administer oxytocin or methylergonovine to help stop bleeding
    • D&C cannot be done after 14 wks gestation b/c of danger of excessive bleeding

Question 8

complete abortion

Answer 8

• occurs when all products of conception are passed from uterus
  
  • after passage, uterine contractions and bleeding subsides and cervical os closes
  • uterus feels small
  • negative pregnancy test
• only have to intervene if excessive bleeding or infection occur
• woman should rest and watch for bleeding, pain, fever
  
  • do not have sex until follow up with HCP

Question 9

missed abortion

Answer 9

• occurs when fetus dies during first half of pregnancy but is retained in the uterus
  
  • when fetus dies, early signs of pregnancy disappear (nausea, breast tenderness, urinary frequency)
  • uterus stops growing and dec in size which reflects absorption of amniotic fluid and maceration of fetus (discoloration, softening, and tissue degeneration)
• mgmt:
  
  • U/S confirms fetal death
    
    • no fetal heart activity can be found
    • hCG will be decreasing
  • D&C or D&E are done
    
    • PGs or misoprostol may be needed to induce contractions to expel the fetus
  • 2 complications:
    
    • infection
    • DIC

Question 10

recurrent spontaneous abortion

Answer 10

• 3 or more spontaneous abortions
• primary causes: genetic or chromosomal abnormalities and anomalies of the reproductive tract (such as bicornuate uterus) or incompetent cervix
• mgmt:
  
  • examine woman’s body for anomalies
  • genetic screening for woman and partner
  • cerclage: procedure to prevent early dilation of cervix may be done if abortions caused by cervical incompetence
  • RhoGAM can be given to woman with Rh negative blood

Question 11

nursing considerations for abortion

Answer 11

• psychological care: help them to grieve, answer questions
• listen to the woman and observe how she behaves
• convey acceptance of the feelings expressed
• teach that grief may last from 6 mos to one year

Question 12

DIC

Answer 12

• occurs when anticoagulation is occurring, inappropriate coagulation also is occurring in the microcirculation
  
  • tiny clots form in tiny blood vessels–>block blood flow to organs–>ischemia
• clotting mechanisms activated inappropriately
  
  • consumption of platelets, fibrinogen, prothrombin, factor V and VIII occur and then they are consumed, the blood becomes deficient in clotting factors and can’t clot
• labs results establish dx: fibrinogen and platelets dec, PT and PTT may be prolonged
• tx: correct the cause
  
  • blood replacement

Question 13

dz that cause DIC fall into 3 major groups:

Answer 13

• infusion of tissue thromboplastic into the circulatino, which consumes other clotting factors
  
  • ie placetal abruption, prolonged retention of a dead fetus
• conductions characterized by endothelial damage:
  
  • ie severe preeclampsia
  • ie HELLP: hemolysis, elevated levels of liver enzymes, and low platelet levels)
• nonspecific effects of some dz:
  
  • ie maternal sepsis, amniotic fluid embolism

Question 14

nursing considerations of DIC

Answer 14

• if have a dz that inc risk of DIC, nurse should observe for bleeding from unexpected sites
  
  • sites for IV insertion or lab work, nosebleeds, or spontaneous bruising
• if coagulation studies are abnormal, an epidural block may be contraindicated

Question 15

ectopic pregnancy

Answer 15

• implantation of fertilized ovum in an area outside the uterine cavity
• can lead to maternal death from hemorrhage
• leads to scarring of fallopian tubes
• pelvic infection (chlamydia and gonorrhea), failed tubal ligation, and hx of ectopic pregnancy in risk
  
  • also inc risk: IUDs, low dose progesterone contraceptives, assistive reproductive technology

Question 16

manifestations of ectopic pregnancy

Answer 16

• missed menstrual period
• positive pregnancy test
• abdominal pain
• vaginal spotting
• signs can depend on exactly where the implantation takes place
  
  • if in distal fallopian tube, can support embryo longer, so may experience normal early signs of pregnancy
  • if in proximal fallopian tube, can rupture tube in 2-3 weeks and cause sudden, severe pain in lower quadrants and abdominal hemorrhage which causes radiating pain under the scapula
    
    • hypovolemic shock is a concern

Question 17

mgmt and nursing considerations for ectopic pregnancy

Answer 17

• mgmt depends on if tube is intact or ruptured
  
  • goal is to preserve tube and improve chance of future fertility
  • methotrexate can be used to inhibit cell division of developing embryo
  • surgical mgmt if unruptured–>linear salpingostomy to salvage the tube
  • surgical mgmt if ruptured–>control bleeding and prevent hypovolemic shock
    
    • when CV is stable, salpingectomy (removal of tube) w/ ligation of bleeding vessels may be required
• nurses should focus on early identification of hypovolemic shock, pain control, and psych support
  
  • administer analgesics
  • teach about SEs of methotrexate: n/v
  • edu about refraining from drinking alcohol, taking vits with folic acid, and having sexual intercourse

Question 18

what are the 2 main causes of hemorrhage after 20 weeks of gestation?

Answer 18

• placenta previa
• placental abruption

Question 19

placenta previa

Answer 19

• implantation of uterus in the lower uterus–>placenta closer to the internal cervical os
• 3 types depending on how much the internal cervical os is covered by the placenta: total, partial, marginal
  
  • marginal: placenta implanted more than 3 cm from internal cervical os
  • partial: lower border of placenta w/in 3 cm of internal cervical os but does not completely cover os
  • totaL: completely covered os
• more common in: older women, multiparas, women who have had C?S, and women who have had suction currettage
• inc risk if: African/Asian ethnicity, cigarette smoking and cocaine use, and male fetus

Question 20

clinical manifestations of placenta previa

Answer 20

• classic sign is sudden onset of painless uterine bleeding in second half of pregnancy
  
  • results from tearing of placental villi from uterine wall
• dx by U/S
  
  • do not manually exam vagina until location and position of placenta verified

Question 21

mgmt and nursing considerations of placenta previa

Answer 21

• mgmt: evaluate women to determine amount of hemorrhage and monitor the fetus
  
  • also must consider gestational age
  • maintain stable CV status for mother
  • try to delay birth to inc birth weight and also administer corticosteroids to mother to speed maturation of fetal lungs
  • home care criteria:
    
    • no evidence of active bleeding, bed rest, short distance from hospital, can verbalize risks
  • no intercourse to prevent disruption of fetus

Question 22

placental abruption

Answer 22

• separation of normally implanted placenta before the fetus is born
• occurs in cases of bleeding and formation of a hematoma on maternal side of the placenta
  
  • as the clot expands, further separation occurs
• dangers for woman: hemorrhage, hypovolemic shock, clotting abnormalities (DIC)
• dangers for fetus: asphyxia, excessive blood loss, prematurity

Question 23

etiology of placental abruption

Answer 23

• inc risk: cocaine use (due to vasoconstriction–>abruption), maternal HTN, cigarette smoking, multigravida status, short umbilical cord, abdominal trauma, premature ROM, hx of previous premature separation, maternal age

Question 24

manifestations of placental abruption

Answer 24

• bleeding: may be evident vaginally or concealed behind placenta
• uterine tenderness localized at site of abruption
• uterine irritability w/ frequent low intensity contractions and poor relaxation b/w contractions
• abdominal or low back pain that is described as dull/aching
  
  • may be suffen and severe or intermittent and difficult to distinguish from labor contractions
• high uterine resting tone identified with intrauterine pressure catheter
  
  • uterus becomes boardlike and tender
• also may show: nonreassuring FHR, back pain, signs of hypovolemic shick
• amniotic fluid may be a port wine color

Question 25

nursing considerations and mgmt of placental abruption

Answer 25

• mgmt:
  
  • if mild and under 34 weeks, bed rest, tocolytic use, administration of corticosteroids
  • if fetal compromise of excessive bleeding: immediate delivery
    
    • blood products for replacement and 2 large bore IV placed for fluid replacement
• may be very frightening b/c of pain and apprent danger
  
  • if C/S is necessary, woman may feel pwerless and nurse should help explain what is going on
  • excessive bleeding and fetal hypoxia are major concerns and nurse should monitor for these

Question 26

hyperemesis gravidarum (HEG)

Answer 26

• most n/v in pregnancy should end by 13-14 weeks
• HEG is persistent, uncontrollable vomiting that begins in first weeks of pregnancy and may continue throughout pregnancy
  
  • can have serious consequences (morning sickness is self limiting and has no seirous complications):
    
    • loss of 5% or more of pre-pregnancy weight, dehydration, acidosis from starvation, elevated levels of blood and urine ketones, alkalosis from loss of HCl in gastric fluids, and hypokalemia
    • short term hepatic dysfunction w/ elevated liver enzymes
    • deficiency of vit K–>coagulation disorders
    • deficiency of thiamine–>encephalopathy

Question 27

etiology of HEG

Answer 27

• cause is not known, but more common among unmarried white women, during first pregnancies, and in multifetal pregnancies
• possible causes include allergy to fetal proteins, elevation of pregnancy hormones, maternal thyroid dysfunction, h. pylori

Question 28

clinical manifestations of HEG

Answer 28

• persistent n/v
• weight loss
• thirst
• oliguria
• dry mucous membranes/skin
• poor skin turgor
• constipation
• lethargy
• inc urine specific gravity (>1.025)
• hypovolemia: hypoTN and tachycardia
• labs: inc BUN and hct, dec Na/K/Cl

Question 29

therapeutic mgmt of HEG

Answer 29

• should first exclude other causes of persistent n/v
• lab studies include H&H which may be elevated b/c of dehydration
  
  • electrolytes: dec Na, K, and Cl
  • elevated Cr
• tx:
  
  • correct dehydration: IV fluids may be necessary
  • antiemetics: ondansetron, promethazine, H2 receptor antagonistis, PPIs, metoclopramide
  • improve nutrition:
    
    • vitamin B6 (pyridoxine)
    • diet

Question 30

nursing considerations for HEG

Answer 30

• monitor V/S and monitor I&Os
• daily weights
• monitor U/S for growth
• monitor urine for ketones which can indicate fat stores being broken down to meet energy needs
• monitor for signs of dehydration: dec fluid intake, dec urine output, inc urine SG, dry mucous membranes/skin, skin turgor
• monitor labs: BMP, H&H
• to reduce n/v:
  
  • small portions of food
  • do not eat foods with strong odors
  • carbs are more easily digested
  • take soups and liquids b/w meals
  • sit up after meals
• maintain nutrition and fluid balance
  
  • eat every 2-3 hours
  • salt the food to replace chloride lost in HCl thru vomit
  • consume K and Mg rich foods
  • IV fluids and TPN if needed
• social support:
  
  • allow verbalization of impact
  • explore reluctance to accept pregnancy
  • recognize lack of support available

Question 31

gestational trophoblastic dz

Answer 31

• AKA hydatidiform mole–>developmental anomaly of the placenta
• occurs when trophoblasts develop abnormally, so the abnormality of the placenta develops, and if present, a fetus will have a fatal chromosomal abnormality
• inc risk at both ends of reproductive life and inc risk among Asian women
  
  • inc risk if have already had one GTD
• presents as an edematous grapelike cluster on U/S
• may or may not be malignant
  
  • may develop into choriocarcinoma

Question 32

clinical manifestations of GTD

Answer 32

• higher levels of hCG than expected for gestation
• characteristic snowstorm U/S pattern that shows the vesicles and absence of a fetal sac or fetal hear activity
• uterus larger than expected for gestational age
• vaginal bleeding: varies from dark brown spotting to profuse hemorrhage
• excessive n/v (HEG) which may be related to elevated hCG
• early development of preeclampsia (usually not diagnosed until 24 weeks in “normal” pregnancy)

Question 33

mgmt of GTD

Answer 33

• medical mgmt:
  
  • evacuation of trophoblastic tissue of the mole
  • continuous f/u of the woman to detect malignant changes of any remaining trophoblastic tissue
• CXR, CT scan, or MRI can be used to detect metastatic dz
• may need CBC, type and screen in case transfusion is needed
• mole usually removed by vacuum aspiration followed by curettage
  
  • then give oxytocin to contract uterus, but should AVOID oxytocin before evacuation b/c tissue can become embolized if given before
• f/u to check for malignancy

Question 34

four categories of HTN during pregnancy

Answer 34

• gestational HTN: BP elevation after 20 weeks of pregnancy NOT accompanied by proteinuria
  
  • may progress to preeclampsia
  • if persists after birth, then called chronic HTN
• preeclampsia: systolic BP of 140 or greater OR diastolic BP of 90 or greater after 20 weeks gestation accompanied by significant proteinuria
  
  • edema is present but non-specific for pre-eclampsia
• eclampsia: progression of preeclampsia to generalized seizures
• chronic HTN: elevated BP was known to exist before pregnancy or before 20 weeks

Question 35

preeclampsia: risk factors

Answer 35

• major cause of perinatal death and IUGR
• risk factors:
  
  • 1st pregnancy
  • 1st pregnancy for father of baby or man who has previously fathered one preeclamptic pregnancy
  • age >35
  • anemia
  • hx of PIH
  • chronic HTN
  • obesity
  • DM
  • multifetal pregnancy
  • African Americans

Question 36

patho of preeclampsia

Answer 36

• result of generalized vasospasm
  
  • peripheral vascular resistance inc b/c some women are sensitive to Ang II and may have a dec in vasodilators
  • vasospasm dec diameter of blood vessels–>endothelial damage–>circulation to body organs is dec
• ratio of thromboxane to prostacyclin increases
• only cure is to deliver the baby

Question 37

patho of altered metabolism related to pre-eclampsia: thromboxane vs. prostacyclin

Answer 37

• thromboxane:
  
  • from kidney and trophoblastic tissue
  • vasoconstrictor
  • platelet aggregation
  • uterine irritability
  • dec utero placental blood flow
• prostacyclin:
  
  • from placenta and endothelial cells
  • vasodilator
  • inhibits platelet aggregation
  • dec uterine activity
  • inc uterine blood flow

Question 38

patho of renal perfusion w/ preeclampsia

Answer 38

• decreased renal perfusion occurs with pre-eclampsia which causes a reduced GFR
  
  • BUN, creatinine, and uric acid levels rise
  • protein leaks across glomerular membrane
    
    • loss of protein from kdineys reduces colloid osmotic pressure and allows fluid to shift to interstitial spaces–>edema and reduction of intravascular volume which causes inc viscosity of blood and rise in hct level
      
      • b/c of reduced intravascular volume, Ang II and aldosterone triggers retention of water and Na which resultsin further vasospasm and HTN–>edema worsens

Question 39

patho of liver circulation as it relates to pre-eclampsia

Answer 39

• reduced liver circulation impairs function and leads to hepatic edema and subcapsular hemorrhage–>hemorrhagic necrosis
  
  • shows as elevated liver enzymes and epigastric pain occurs

Question 40

patho of cerebral circulation as it relates to pre-eclampsia

Answer 40

• vasoconstriction of cerebral vessels leads to pressure induced rupture of thin walled capillaries–>small cerebral hemorrhage
  
  • S/S: HA, cisual disturbances (spots before the eyes), hyperactive DTRs

Question 41

patho of pulmonary circulation as it relates to pre-eclampsia

Answer 41

• decreased colloid oncotic pressure can lead to pulmonary capillary leak–>pulmonary edema
  
  • dyspnea is primary symptom

Question 42

patho of nutritional deficiency as it relates to pre-eclampsia

Answer 42

• low protein: protein responsible for cellular growth
• hypomagnesemia: magnesium is a vasodilator
• calcium: inverse relationship b/w calcium intake and incidence of eclampsia

Question 43

prenatal preventive measures for pre-eclampsia

Answer 43

• monitor weight gain, BP, and urinary protein level

Question 44

complications of pre-eclampsia

Answer 44

• placental abruption
• hematologic problems: DIC, thrombocytopenia
• CVS
• renal failure
• hepatic failure
• newborn complications:
  
  • SGA r/t utero placental insufficiency
  • reduced amniotic fluid
  • intrauterine fetal death

Question 45

clinical manifestations of pre-eclampsia

Answer 45

• classic signs: first sign is usually HTN
  
  • proteinuria (identified w/ clean catch urine specimen)
• additional signs:
  
  • retina: vascular constriction and narrowing of small arteries
  • hyperactive DTRs
  • labs: liver or renal dysfunction
    
    • coagulation may be impaired and platelets dec
  • generalized edema: may first show as rapid weight gain
• symptoms:
  
  • continuous HA
  • drowsiness
  • mental confusion
  • visual disturbances: blurred/double vision
  • numbness/tingling of hands or feet
  • epigastric pain
  • dec urinary output

Question 46

diagnostic criteria for mild pre-eclampsia

Answer 46

• BP: 140/90 on 2 occasions 6 hours apart
• proteinuria: 300 mg in 24 hour period, or trace to 1+/2+ by urine dipstick
• I&O
• transient HA
• hyperreflexia 2+ or 3+
• no clonus

Question 47

mgmt of mild preeclampsia

Answer 47

• IV mag sulfate
• antiHTN therapy
• corticosteroids to accelerate fetal lung maturity if <34 weeks
• activity restriction: rest frequently
  
  • lateral position for at least 1.5 hours/day dec pressure of vena cava and inc cardiac return and circulatory volume
• BP: BP should be checked in same arm and in the same position 2-4 times/day
• weight: weight each morning
• urinalysis: urine dipstick for protein using first void daily
• fetal monitoring: kcik counts, U/S, BPP
• diet: need ample protein and calories
  
  • diet w/o salt or fluid restriction

Question 48

labs to manage pre-eclampsia

Answer 48

• magnesium levels
• liver fcn tests
• CBC w/ platelets
• LDH
• uric acid
• serum creatinine
• bilirubin
• 24 hour urine for protein and creatinine clearance
  
  • need to deliver if unstable or HELLP occurs

Question 49

assessment for pre-eclampsia

Answer 49

• CHHURN:
  
  • Cardiovascular system
  • Hematologic system
  • Hepatic system
  • Uteroplacental system
  • Renal system
  • Neurological system

Question 50

assessment of CV system for pre-eclampsia

Answer 50

• assess V/S:
  
  • BP w/ client in left lateral recumbent position
  • pulse
  • respirations
  • temp q4 hrs
  • FHR: continuously

Question 51

assessment of hematologic system for pre-eclampsia

Answer 51

• assess for bleeding:
  
  • petechia
  • bruising
  • epistaxis
  • gingival bleeding
  • hematuria
  • excessive vaginal bleeding
  • conjunctival hemorrhage
  • oozing from incision/puncture site

Question 52

assessment of hepatic system w/ preeclampsia

Answer 52

• assess n/v:
  
  • RUQ or epigastric pain
  • portal HTN may result in epigastric pain and may precede hepatic rupture
• monitor lab values: liver function studies–>SGOT, SGPT, AST, ALT

Question 53

assessment of uteroplacental system w/ preeclampsia

Answer 53

• antepartum:
  
  • EFM
  • NST
  • BPP
  • U/S
• intrapartum:
  
  • continuous fetal monitoring

Question 54

assessment of renal system w/ preeclampsia

Answer 54

• daily weights: inquire about weight gain
• assess edema
• monitor I&O and urine protein
  
  • notify HCP if <30 mL/hour
• monitor lab values:
  
  • inc BUN, Cr, and uric acid
  • renal damage as indicated by oliguria

Question 55

assessment of neurological system w/ preeclampsia

Answer 55

• assess neuro deficits and LOC
• HAs from CNS irritability–>severe or continuous
• visual disturbances: blurred vision, seeing spots of flashing lights, diplopia
• drowsy/dizziness
• assess DTRs and clonus q1 hr
  
  • patellar and/or biceps reflexes

Question 56

assessment of clonus w/ preeclampsia

Answer 56

• clonus:
  
  • position client w/ legs dangling over edge of examining table
  • support leg w/ one hand and sharply dorsiflex the client’s foot w/ other hand
  • maintain dorsiflexed position for a few seconds then release foot

Question 57

negative vs. positive clonus

Answer 57

• negative clonus (normal):
  
  • 0 beats
  • foot remains steady: no rhythmic oscillations when foot dorsiflexed
  • when released, foot drops to flexed position w/ no oscillations
• positive clonus (abnormal):
  
  • 1-4 beats
  • rhythmic oscillations when dorsiflexed
  • similar oscillations when foot drops to plantar flexed position

Question 58

diagnostic criteria for severe pre-eclampsia

Answer 58

• BP over 160/110 2 readings, 6 hrs apart while on bed rest
• proteinuria >5 g in 24 hr or 3+ or higher on urine dipstick
• elevated creatinine
• dec platelets
• elevated liver enzymes
• oliguria
• severe, unrelenting HA
• visual disturbances present
• n/v/epigastric pain
• hyperreflexia w/ or w/o clonus
• pulmonary edema or cyanosis
• thrombocytopenia
• fetus: growth restriction and reduced amniotic fluid volume

Question 59

HELLP syndrome

Answer 59

• hemolysis, elevated liver enzymes, and low platelets
• may be assoc with preeclampsia and develop during third trimester
• client at risk for:
  
  • hemorrhage
  • pulmonary edema
  • hepatic rupture
• tx: mag sulfate to control seizures and hydralazine to control BP
  
  • fluid replacement is managed to avoid worsening reduced intravascular volume
  • if woman is near term and has a favorable cervix, induction of labor is preferred to avoid bleeding and clotting complications

Question 60

signs of impending seizures

Answer 60

• hyperreflexia, and possible clonus
• inc signs of cerebral irritability (HA, visual disturbance)
• epigastric or RUQ pain, n/v

Question 61

seizure preventive measures

Answer 61

• reduce external stimuli
• quiet room with door closed
• pad door to reduce noise
• keep lights low and noise to a minimum
• block phone calls
• group nursing assessments to allow woman periods of undisturbed rest
• avoid bumping bed or startling woman
• restrict visitors

Question 62

how to prevent seizure related injury

Answer 62

• padded side rails
• O2 and suction equipment
• preeclampsia box:
  
  • medium plastic airway
  • ambu bag w/ mask
  • ophthalmoscope
  • tourniquet
  • reflex hammer
  • syringes and needles
  • meds: mag sulfate, calcium gluconate

Question 63

how to protect a woman during a seizure

Answer 63

• stay w/ pt and call for help
• turn onto side during tonic phase to permit greater circulation to placenta and prevent aspiration
• note time and sequence
  
  • eclampsia marked by tonic clonic seizure preceded by facial twitching
• insert airway after seizure
• suction mouth and nose
• O2 by mask at 8-10 L/min
• notify HCP
• prepare for med administration

Question 64

administration and antidote of magnesium sulfate

Answer 64

• administration:
  
  • infusion pump: piggyback into mainline IV
  • loading dose: 4-6 g then 1-3 g/hour
• antidote: calcium gluconate–>10 mL of a 10% soln IV push over 10 min

Question 65

serum levels of magnesium sulfate

Answer 65

• 4-8 mg/dL: therapeutic
• 9-12 mg/dL: loss of reflexes
• 15-17 mg/dL: respiratory and muscular paralysis
• 30-35 mg/dL: cardiac arrest

Question 66

class and action of magnesium sulfate

Answer 66

• class:
  
  • beta adrenergic agent
  • anticonvulsant
  • tocolytic
• action:
  
  • CNS depressant
  • competes w/ calcium to reduce muscle excitation to slow and stop uterine activity
  • lowers seizure threshold

Question 67

maternal SEs to mag sulfate

Answer 67

• flushing
• HA
• dry mouth
• dizziness
• lethargy
• pulmonary edema

Question 68

fetal SEs to mag sulfate

Answer 68

• drug crosses placenta
• dec in FHR variability
• hypotonia
• lethargy
• respiratory depression

Question 69

signs of mag toxicity

Answer 69

• resp rate <12 breaths per min
• maternal pulse ox reading less than 95%
• absence of DTRs
• sweating, flushing
• altered sensorium: condused, lethargic, slurred speech, drowsy
• hypoTN
• serum magnesium value above 4-8 mg/dL

Question 70

nursing considerations with mag sulfate

Answer 70

• monitor magnesium and calcium levels
• monitor DTRs
• continuous FHR monitoring
• baseline maternal V/S, then q2-4 hours
• assess resp status
  
  • RR rate: d/c if <12
  • auscultate lungs
• monitor strict I&O
  
  • urinary output of 30 mL/hour
  • titrate IV and PO fluids
• postpartum:
  
  • continue magnesium 24-48 hours
    
    • strict I&O

Question 71

respond to signs of mag sulfate toxicity

Answer 71

• notify HCP
• obtain mag sulfate level
• monitor mag sulfate levels q12 hours
• dec mag sulfate per protocol
• monitor fetal well being
• administer calcium gluconate as ordered
• continue close monitoring of client

Question 72

nursing considerations with mag sulfate toxicity

Answer 72

• monitor CNS status: changes indicate cerebral hypoxia or impending seizure
• provide quiet, low stimulus env, limit visitors
• provide bedrest: position client in left lateral position
• monitor DTR and presence of clonus
• monitor FHR and contraction pattern
• provide adequate fluids
• protect client from injury
  
  • initiate seizure precautions
  • administer seizure meds
• prepare for delivery after stabilization of client

Question 73

super imposed pre-eclampsia

Answer 73

• woman who has chronic HTN with pre-eclampsia superimposed
• worse prognosis for mother and fetus
• inc risk for:
  
  • placental abruption
  • acute renal failure
  • IUGR
  • fetal demise
  • maternal demise
• closely monitor chronic HTN if proteinuria develops or when edema occurs in upper half of body
• serum uric acid is helpful in confirming dx of superimposed PIH

Question 74

eclampsia

Answer 74

• pre-eclampsia that has progressed to include maternal tonic clonic seizures

Question 75

support for family after an eclamptic seizure

Answer 75

• explain what happened
• don’t minimize seriousness
• explain that it lasts a few min, pt is unconscious, drowsy for some time
• acknowledge that seizure indicates worsening of condition
• HCP will determine future mgmt
  
  • may include delivery