Exam 3 - Chapter 27

Question 1

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

Answer 1

C - Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick
value of 3+ alerts thenurse 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 2

Thelabor of a pregnant woman with preeclampsia is going to be induced. Before
initiating the oxytocin (Pitocin) infusion, the nurse reviews the womans 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

Answer 2

C - 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 thepresence of seizures. DIC is a potential
complication associated with HELLP syndrome. Idiopathic thrombocytopenia is thepresence of
low platelets of unknown cause and is not associated with preeclampsia.

Question 3

A woman with preeclampsia has a seizure. What is the nurses highest priority during a
seizure?
a. To insert an oral airway
b. To suction the mouth to prevent aspiration
c. To administer oxygen by mask
d. To stay with the client and call for help

Answer 3

D - If a client becomes eclamptic, then thenurse should stay with theclient 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 thestandard of care. Thenurse
should attempt to keep theairway patent by turning theclients head to theside to prevent
aspiration. Once theseizure has ended, it may be necessary to suction theclients mouth. Oxygen
is administered after theconvulsion has ended

Question 4

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
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, Im so thirsty
and warm. What is the nurses immediate action?
a. To call for an immediate magnesium sulfate level
b. To administer oxygen
c. To discontinue themagnesium sulfate infusion
d. To prepare to administer hydralazine

Answer 4

C - Regardless of themagnesium level, theclient is displaying theclinical signs and symptoms of
magnesium toxicity. Thefirst action by thenurse should be to discontinue theinfusion of
magnesium sulfate. In addition, calcium gluconate, theantidote for magnesium, may be
administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension in
severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than 160
mm Hg or a diastolic BP higher than 110 mm Hg.

Question 5

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

Answer 5

D - Uterine tenderness in the presence of increasing tone may be the earliest sign of abruptio
placentae. Women with preeclampsia are at increased risk for an abruption attributable to
decreased placental perfusion. Eclamptic seizures are evidenced by the presence of generalized
tonic-clonic convulsions.

Question 6

A woman with worsening preeclampsia is admitted to the hospitals 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 boys2
years and 4 years of ageto visit their mother.
d. I will stay with my wife during her labor, just as we planned.

Answer 6

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 wifes condition
from worsening. Implementing breathing techniques is indicative of adequate knowledge related
to pain management during labor. Administering ice chips indicates an understanding of
nutritional needs during labor. Staying with his wife during labor demonstrates the husbands
support for his wife and is appropriate.

Question 7

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

Answer 7

D - High serum levels of magnesium can cause a relaxation of smooth muscle such as the uterus.
Because of this tocolytic effect, the client will most likely have a boggy uterus with increased
amounts of bleeding. All women experience uterine bleeding in the postpartum period, especially
those who have received magnesium therapy. Rather than scant lochial flow, however, this client
will most likely have a heavy flow attributable to the relaxation of the uterine wall caused by
magnesium administration

Question 8

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 nurses 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 dont know why it is taking so long.
c. The length of labor varies for different women.
d. Your baby is just being stubborn

Answer 8

A - 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.`

Question 9

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

Answer 9

A - Risk for injury is the most appropriate nursing diagnosis for this client scenario. Gas exchange is
more likely to become impaired, attributable to pulmonary edema. A risk for excess, not
deficient, fluid volume, related to increased sodium retention, is increased, and a risk for
decreased, not increased, cardiac output, related to the use of antihypertensive drugs, also is
increased.

Question 10

Which statement best describes chronic hypertension?
a. Chronic hypertension is defined as hypertension that begins during pregnancy and lasts
for the duration of the pregnancy.
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.
c. Chronic hypertension is general hypertension plus proteinuria.
d. Chronic hypertension can occur independently of or simultaneously with preeclampsia.

Answer 10

D - Women with chronic hypertension may develop superimposed preeclampsia, which increases
themorbidity for both themother and thefetus. Chronic hypertension is present before pregnancy
or
diagnosed before the20 weeks of gestation and persists longer than 6 weeks postpartum. Chronic
hypertension becomes severe with a diastolic BP of 110 mm Hg or higher. Proteinuria is an
excessive concentration of protein in theurine and is a complication of hypertension, not a
defining characteristic.

Question 11

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

Answer 11

A - By 34 weeks of gestation, therisk of continuing thepregnancy may be considered greater than
therisks of a preterm birth. Strict bed rest is controversial for mild cases; some women in
the hospital are even allowed to move around.

Question 12

What is theprimary purpose for magnesium sulfate administration for clients with
preeclampsia and eclampsia?
a. To improve patellar reflexes and increase respiratory efficiency
b. To shorten the duration of labor
c. To prevent convulsions
d. To prevent a boggy uterus and lessen lochial flow

Answer 12

C - Magnesium sulfate is thedrug of choice used to prevent convulsions, although it can generate
other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium
toxicity. Magnesium sulfate can also increase theduration of labor. Women are at risk for a
boggy uterus and heavy lochial flow as a result of magnesium sulfate therapy.

Question 13

TheAmerican 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

Answer 13

C - Three risk factors are present in the19-year-old African-American client. She has AfricanAmerican ethnicity, is at theyoung end of theage distribution, and has a multiple pregnancy. In
planning care for this client, thenurse must frequently monitor her BP and teach her to recognize
theearly warning signs of preeclampsia. The30-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 the41-year-old Caucasian primigravida client

Question 14

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 theresult of prolonged bed
rest?
a. Thrombophlebitis
b. Psychologic stress
c. Fluid retention
d. Cardiovascular deconditioning

Answer 14

C - No evidence has been found that supports thepractice of bed rest to improve pregnancy outcome.
Fluid retention is not an adverse outcome of prolonged bed rest. Thewoman is more likely to
experience diuresis with accompanying fluid and electrolyte imbalance and weight loss.
Prolonged bed rest is known to increase therisk for thrombophlebitis. Psychologic stress is
known to begin on thefirst day of bed rest and continue for theduration of thetherapy.
Therefore, restricted activity, rather than complete bed rest, is recommended. Cardiovascular
deconditioning is a known complication of bed rest.

Question 15

Which neonatal complications are associated with hypertension in the mother?

a. Intrauterine growth restriction (IUGR) and prematurity
b. Seizures and cerebral hemorrhage
c. Hepatic or renal dysfunction
d. Placental abruption and DIC

Answer 15

A - 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 16

Thenurse has evaluated a client with preeclampsia by assessing DTRs. Theresult is a
grade of 3+. Which DTR response most accurately describes this score?
a. Sluggish or diminished
b. Brisk, hyperactive, with intermittent or transient clonus
c. Active or expected response
d. More brisk than expected, slightly hyperactive

Answer 16

D - DTRs reflect thebalance between thecerebral cortex and thespinal cord. They are evaluated at
baseline and to detect changes. A slightly hyperactive and brisk response indicates a grade 3+
response.

Question 17

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

Answer 17

A - Hydralazine is an antihypertensive medication commonly used to treat hypertension in severe
preeclampsia. Typically, it is administered for a systolic BP higher than 160 mm Hg or a
diastolic BP higher than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered
for increasing signs of CNS irritability related to severe preeclampsia (e.g., clonus)

Question 18

Theclient being cared for has severe preeclampsia and is receiving a magnesium sulfate

infusion. Which new finding would give thenurse cause for concern?
a. Sleepy, sedated affect
b. Respiratory rate of 10 breaths per minute
c. DTRs of 2
d. Absent ankle clonus

Answer 18

B - A respiratory rate of 10 breaths per minute indicates theclient is experiencing respiratory
depression from magnesium toxicity. Because magnesium sulfate is a CNS depressant, theclient
will most likely become sedated when theinfusion is initiated. DTRs of 2 and absent ankle clonus
are normal findings.

Question 19

What is themost common medical complication of pregnancy?

a. Hypertension
b. Hyperemesis gravidarum
c. Hemorrhagic complications
d. Infections

Answer 19

A - Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage of
pregnant women will have nausea and vomiting,

Question 20

Which statement most accurately describes theHELLP syndrome?

a. Mild form of preeclampsia
b. Diagnosed by a nurse alert to its symptoms
c. Characterized by hemolysis, elevated liver enzymes, and low platelets
d. Associated with preterm labor but not perinatal mortality

Answer 20

C - Theacronym HELLP stands for hemolysis (H), elevated liver (EL) enzymes, and low platelets
(LP). TheHELLP syndrome is a variant of severe preeclampsia and is difficult to identify
because thesymptoms are not often obvious. TheHELLP syndrome must be diagnosed in
thelaboratory. Preterm labor is greatly increased; therefore, so is perinatal mortality.

Question 21

Which adverse prenatal outcomes are associated with theHELLP syndrome? (Select all 
that apply.)
a. Placental abruption
b. Placenta previa
c. Renal failure
d. Cirrhosis
e. Maternal and fetal death

Answer 21

A,C,E - TheHELLP syndrome is associated with an increased risk for adverse perinatal outcomes,
including placental abruption, acute renal failure, subcapsular hepatic hematoma, hepatic rupture,
recurrent preeclampsia, preterm birth, and fetal and maternal death. TheHELLP syndrome is
associated with an increased risk for placental abruption, not placenta previa. It is also associated
with an increased risk for hepatic hematoma, not cirrhosis.

Question 22

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 clients 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.

Answer 22

A,B,E - BP readings are easily affected by maternal position. Ideally, theclient should be seated. An
alternative position is left lateral recumbent with thearm at thelevel of theheart