Chapter 27 – Hypertensive Disorders-( Test Questions ) Flashcards
A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?
Dipstick value of 3+ for protein in her urine
The finding of greatest concern is a dipstick value of 3+ for protein in her urine.
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?
HELLP syndrome
A woman with preeclampsia has a seizure. What is the nurse’s highest priority during a seizure?
To stay with the client and call for help
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?
To discontinue the magnesium sulfate infusion
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?
Abruptio placentae
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?
“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.”
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?
Boggy uterus with heavy lochia flow
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’smost appropriate response?
The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor.”
What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?
Risk for injury to mother and fetus, related to central nervous system (CNS) irritability
What best describes chronic hypertension?
Chronic hypertension can occur independently of or simultaneously with preeclampsia.
Which intervention is most important when planning care for a client with severe gestational hypertension?
Induction of labor is likely, as near term as possible.
What is the primary purpose for magnesium sulfate administration for clients with preeclampsia and eclampsia?
Prevent convulsions
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?
19-year-old African American who is pregnant with twins
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?
Fluid retention
Which neonatal complications are associated with hypertension in the mother?
Intrauterine growth restriction (IUGR) and prematurity
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?
More brisk than expected, slightly hyperactive
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?
Hydralazine
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?
Respiratory rate of 10 breaths per minute
What is the most common medical complication of pregnancy?
Hypertension
Which statement most accurately describes the HELLP syndrome?
Hemolysis, elevated liver enzymes, and low platelets
Which adverse prenatal outcomes are associated with the HELLP syndrome? (Select all that apply.)
a. Placental abruption c. Renal failure e. Maternal and fetal death
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 e. The same arm should be used for every reading.
