Pre-eclampsia, Eclampsia > Maternal & Newborn
Exam Review
Fetal Complications
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is caring for a client who is 32 weeks pregnant and has been diagnosed with mild preeclampsia.
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
Explanation
The correct answer is choice A, C and D. Here is why:
• Choice A is correct because monitoring blood pressure and urine protein daily is a standard intervention for mild preeclampsia to detect any worsening of the condition.
• Choice B is wrong because magnesium sulfate is not prescribed for mild preeclampsia, but for severe preeclampsia or eclampsia to prevent seizures.
• Choice C is correct because encouraging bedrest in left lateral position can improve uteroplacental perfusion and reduce blood pressure in mild preeclampsia.
• Choice D is correct because teaching the client to report headache or visual changes can help identify signs of severe preeclampsia or impending eclampsia, which require immediate medical attention.
• Choice E is wrong because restricting fluid intake to 1.5 L per day is not indicated for mild preeclampsia and can cause dehydration and electrolyte imbalance.
Normal ranges for blood pressure and urine protein in pregnancy are:
• Blood pressure: less than 140/90 mmHg
• Urine protein: less than 300 mg/24 hours
A nurse is reviewing the laboratory results of a client who is 36 weeks pregnant and has severe preeclampsia.
Which of the following findings should the nurse report to the provider immediately?
Explanation
A platelet count of 100,000/mm3 is below the normal range of 150,000 to 450,000/mm3 and indicates thrombocytopenia.Thrombocytopenia is a common coagulation abnormality in preeclampsia and can increase the risk of bleeding complications.
The nurse should report this finding to the provider immediately.
Choice B is wrong because a serum creatinine of 0.8 mg/dL is within the normal range of 0.5 to 1.1 mg/dL for women and does not indicate renal impairment.
Choice C is wrong because a serum uric acid of 6 mg/dL is within the normal range of 2.4 to 6 mg/dL for women and does not indicate hyperuricemia.
Choice D is wrong because a serum albumin of 3.5 g/dL is within the normal range of 3.4 to 5.4 g/dL for adults and does not indicate hypoalbuminemia.
A nurse is preparing to administer an IV infusion of magnesium sulfate to a client who is 38 weeks pregnant and has eclampsia.
Which of the following actions should the nurse take?
Explanation
All of the above.
The nurse should take all of the following actions when administering an IV infusion of magnesium sulfate to a client who has eclampsia:
• Use an infusion pump to regulate the flow rate.
This ensures that the client receives the correct dose of magnesium sulfate and prevents overdose or underdose.Magnesium sulfate is given as a loading dose of 4 g in normal saline solution, followed by a maintenance infusion of 1 to 2 g/h by controlled infusion pump.
• Monitor the client’s deep tendon reflexes hourly.
This is a way to assess the client’s neuromuscular status and detect signs of magnesium toxicity, such as hyporeflexia or areflexia.Magnesium sulfate can cause muscle weakness and respiratory depression if the serum level is too high.
• Keep calcium gluconate readily available.
This is the antidote for magnesium toxicity and should be given if the client develops signs of respiratory depression, cardiac arrhythmias, or loss of consciousness.Calcium gluconate is given as 10 mL of 10% solution IV push over 3 to 5 minutes.
Choice A is wrong because using an infusion pump is not enough to ensure safe administration of magnesium sulfate.
The nurse should also monitor the client’s vital signs, urine output, and serum magnesium level regularly.
Choice B is wrong because monitoring the client’s deep tendon reflexes is not enough to prevent or treat eclamptic seizures.
The nurse should also observe the client for signs of headache, visual disturbances, epigastric pain, or altered mental status.
Choice C is wrong because keeping calcium gluconate available is not enough to prevent complications of magnesium sulfate therapy.
The nurse should also be prepared to manage air circulation.
A nurse is teaching a prenatal class about the risk factors for preeclampsia and eclampsia.
Which of the following statements by a class participant indicates a need for further teaching?
Explanation
“I should take low-dose aspirin every day to prevent preeclampsia.” This statement indicates a need for further teaching because low-dose aspirin is not recommended for all pregnant women, but only for those who have a high risk of developing preeclampsia.Low-dose aspirin may have side effects such as bleeding, allergic reactions, or stomach ulcers.
The nurse should explain that low-dose aspirin is prescribed by the health care provider only after weighing the benefits and risks for each individual case.
Choice A is wrong because eating foods that are high in salt may increase blood pressure and fluid retention, which are signs of preeclampsia.The nurse should advise the client to limit salt intake and avoid processed foods that contain a lot of sodium.
Choice B is wrong because having a family history of preeclampsia is one of the risk factors for developing this condition.
The nurse should encourage the client to inform the doctor about any family history of preeclampsia, as well as other risk factors
A nurse is assessing a client who is 34 weeks pregnant and has mild preeclampsia.
Which of the following findings should alert the nurse to possible progression to severe preeclampsia?
Explanation
Epigastric pain is a sign of severe preeclampsia, which indicates possible damage to the liver.Severe preeclampsia can also cause high blood pressure, proteinuria, headaches, changes in vision, sensitivity to light, fatigue, nausea/vomiting, infrequent urination, or a tendency to bruise easily.
B. Weight gain of 2 kg in one week.Statement is wrong because weight gain of 2 kg in one week is not a sign of severe preeclampsia, but rather a normal occurrence during pregnancy.
C. Facial edema.Statement is wrong because facial edema is a sign of mild preeclampsia, not severe preeclampsia.Mild preeclampsia is characterized by high blood pressure and protein in the urine.
D. Urine output of 40 mL/hr.
Statement is wrong because urine output of 40 mL/hr is not a sign of severe preeclampsia, but rather a normal range for urine output during pregnancy.
Normal urine output ranges from 30 to 60 mL/hr for adults.
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