Pre-eclampsia, Eclampsia
Study Questions
Fetal Complications
A 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.
More Questions on this Topic
A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago.
Which of the following instructions should the nurse include?
Explanation
The nurse should instruct the client to report any headache or visual changes to the doctor immediately, as these are signs of worsening preeclampsia that can lead to serious complications such as stroke, eclampsia, or HELLP syndrome.Preeclampsia can persist or even begin after delivery, most often within 48 hours, so the client should monitor her blood pressure and symptoms until they resolve.
Choice A is wrong because the client should not stop taking her blood pressure medication without consulting her doctor.Blood pressure medication helps lower the blood pressure and protects the organs from damage.The blood pressure usually returns to normal within several days to weeks after delivery, but some clients may need medication for longer.
Choice B is wrong because the client should not avoid breastfeeding her baby unless there is a medical reason to do so.Breastfeeding has many benefits for both the mother and the baby, and does not affect the blood pressure or the preeclampsia.
Choice D is wrong because the client should not limit her fluid intake to prevent fluid overload.Fluid overload is not a common complication of preeclampsia, and limiting fluids can cause dehydration and affect the milk supply for breastfeeding.
The client should drink enough fluids to stay hydrated and follow a balanced diet.
A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.
Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?
Explanation
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia.
Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.
Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.
Normal ranges for the assessments are:
• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)
• Respiratory rate: 12 to 20 breaths per minute
• Urine output: at least 30 mL per hour
• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)
A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate.
Which assessment finding would indicate that the client is experiencing magnesium toxicity?
Explanation
Respiratory rate of 10 breaths/minute.This indicates that the client is experiencingmagnesium toxicity, which can causemuscle weakness,difficulty breathing, andcardiac arrest.The normal respiratory rate for adults is 12 to 20 breaths/minute.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urinary output of 40 mL/hour is within the normal range of 30 to 50 mL/hour.Magnesium toxicity can cause urine retention, not increased output.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L.Magnesium toxicity occurs when the level is above 2.6 mEq/L.
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia.
Which outcome would indicate that the therapy is successful?
Explanation
The client has no seizures or eclampsia.This outcome would indicate that the magnesium sulfate therapy is successful because magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.
Some additional information for the other choices are:
• Choice B. The client delivers a healthy baby vaginally.
This outcome is desirable but not directly related to the effectiveness of magnesium sulfate therapy.Magnesium sulfate can help prolong a pregnancy for up to two days to allow drugs that speed up the baby’s lung development to be administered, but it does not guarantee a vaginal delivery or a healthy baby.
• Choice C. The client has normal blood pressure and urine output.
This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.
Magnesium sulfate may help reduce blood pressure in some cases, but it is not the primary treatment for hypertension in preeclampsia.Other medications such as antihypertensives are usually prescribed for that purpose.Urine output should be monitored closely while receiving magnesium sulfate therapy, as a decrease may indicate toxicity or kidney impairment.Urine output should be at least 30 mL/hour while administering magnesium sulfate.
• Choice D. The client has improved liver function and platelet count.
This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.
Magnesium sulfate does not affect liver function or platelet count in preeclampsia.These parameters may improve after delivery of the placenta, which is the main cause of preeclampsia.
Normal ranges for blood pressure, urine output, liver function and platelet count are:
• Blood pressure: less than 140/90 mm Hg
• Urine output: at least 30 mL/hour
• Liver function: AST and ALT less than 40 U/L, LDH less than 600 U/L, bilirubin less than 1.2 mg/dL
• Platelet count: 150,000 to 450,000 per microliter of blood
A nurse is teaching a pregnant client about the risk factors for pre-eclampsia.
Which of the following should the nurse include? (Select all that apply).
Explanation
The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.
Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.
Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.
Normal ranges for blood pressure and proteinuria in pregnancy are:
• Blood pressure: less than 140/90 mmHg
• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample
A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following assessments is the most important for the nurse to perform?
Explanation
Level of consciousness.
This is because magnesium sulfate, which is given to prevent seizures in severe preeclampsia, can cause respiratory depression and coma if the dose is too high.Therefore, the nurse should monitor the client’s level of consciousness and respiratory rate closely and report any signs of toxicity to the provider.
Choice A is wrong because hourly intake and output is not the most important assessment for this client.However, the nurse should monitor the urinary output as a sign of renal function and fluid balance and report any output less than 30 ml per hour.
Choice B is wrong because deep tendon reflexes are not the most important assessment for this client.However, the nurse should check the reflexes as a sign of neuromuscular irritability and report any hyperreflexia or clonus.
Choice C is wrong because lung sounds are not the most important assessment for this client.However, the nurse should auscultate the lungs as a sign of pulmonary edema and report any crackles or wheezes.
A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.
The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.
The fetal heart rate is 160 beats/minute with late decelerations.
What is the priority nursing action?
Explanation
The correct answer is d. Notify the health care provider.
Rationale for Choice A:
- Increasing the rate of oxytocin infusion is contraindicated in this situation.
- Oxytocin stimulates uterine contractions,and the client is already experiencing excessively frequent and prolonged contractions.
- Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
- It could also put the client at higher risk for uterine rupture,a serious complication associated with oxytocin use.
Rationale for Choice B:
- While administering oxygen is a common intervention for fetal distress,it's not the priority action in this case.
- Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency,which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
- Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.
Rationale for Choice C:
- Turning the client to her left side is a recommended position to improve placental blood flow.
- However,in this situation,it's not the priority action given the presence of late decelerations and excessive uterine contractions.
- It may be a helpful adjunct measure,but it won't address the primary cause of fetal distress.
Rationale for Choice D:
- Notifying the health care provider is the most crucial action because:
- The client has severe pre-eclampsia,a serious condition that requires close monitoring and management.
- The frequent and prolonged contractions,along with late decelerations in the fetal heart rate,indicate potential fetal distress.
- The health care provider needs to be aware of these changes to make timely decisions regarding interventions,such as:
- Adjusting the oxytocin infusion
- Expediting delivery if necessary
- Implementing other measures to improve fetal well-being
- Closely monitoring the mother's condition to prevent complications of pre-eclampsia
A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 34 weeks of gestation.
Which of the following statements by the client indicates a need for further teaching?
Explanation
“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable.She should also follow up with her doctor regularly and monitor her blood pressure at home.
Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.
This can help detect any signs of worsening hypertension or organ damage.
Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.
Eclampsia is a serious complication of pre-eclampsia that causes seizures.
Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia.However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.
Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.
A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia.
Which of the following actions should the nurse take?
Explanation
Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.
Choice B is wrong because magnesium sulfate does not affect blood glucose levels.
There is no need to monitor the client’s blood glucose level every 4 hours.
Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.
A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.
Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.
Increasing the infusion rate can increase the risk of toxicity.
A nurse is teaching a client who is at risk for developing preeclampsia.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%.If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).
Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia.Sodium intake does not affect blood pressure in pregnancy.
Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia.However, lying on your left side may help improve blood flow to your placenta and your baby.
Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia.However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.
A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion.
Which of the following findings should alert the nurse to suspect magnesium toxicity?
Explanation
Respiratory rate 10/min.This indicatesmuscle weaknessanddifficulty breathing, which are symptoms ofmagnesium toxicity.Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.
Choice B.Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr.Urine output may decrease in severe cases of magnesium toxicity due to urine retention.
Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex.A low or absent patellar reflex may indicate magnesium toxicity, as it reflectsmuscle weaknessandnerve dysfunction.
Choice D.Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L.Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.
A nurse is caring for a client who has a diagnosis of HELLP syndrome.
The nurse should monitor the client for which of the following complications? (Select all that apply.)
Explanation
The correct answer is choice A, C, D and E. Here is why:
• Choice A is correct becausedisseminated intravascular coagulation (DIC)is a blood clotting disorder that can develop as a complication of HELLP syndrome.DIC can result in excessive bleeding or blood clots in various organs.
• Choice B is wrong becauseacute kidney injuryis not a common complication of HELLP syndrome.However, preeclampsia can cause kidney damage and proteinuria (high levels of protein in the urine).
• Choice C is correct becausepulmonary edemais a condition where fluid accumulates in and around the lungs, impairing oxygen absorption.It can occur as a complication of HELLP syndrome due to high blood pressure and fluid overload.
• Choice D is correct becauseplacental abruptionis a condition where the placenta separates from the uterus before delivery.
It can cause severe bleeding and fetal distress.It can occur as a complication of HELLP syndrome due to high blood pressure and abnormal blood clotting.
• Choice E is correct becausefetal growth restrictionis a condition where the fetus does not grow as expected.It can occur as a complication of HELLP syndrome due to reduced blood flow and oxygen delivery to the placenta.
Normal ranges for liver enzymes are:
• Alanine aminotransferase (ALT): 7 to 55 units per liter (U/L)
• Aspartate aminotransferase (AST): 8 to 48 U/L
• Alkaline phosphatase (ALP): 45 to 115 U/L
Normal range for platelet count is:
• 150,000 to 450,000 platelets per microlitre.
A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth.
The nurse should instruct the client to report which of the following findings to the provider?
Explanation
Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.
Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.
It is not related to HELLP syndrome.
Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.
It is not related to HELLP syndrome.
Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.
It is not related to HELLP syndrome.
Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.
A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
The client should have a follow-up visit with the provider in a week.This is because preeclampsia can persist or develop after delivery and requires close monitoring of blood pressure and signs of organ injury.
Choice A is wrong because vaginal bleeding is normal after delivery and does not indicate a complication of preeclampsia.
Choice B is wrong because the client should not stop taking blood pressure medication without consulting the provider.Preeclampsia can cause hypertension that may need treatment even after delivery.
Choice C is wrong because breastfeeding is not contraindicated for women with preeclampsia.Breastfeeding may even lower blood pressure and help the uterus contract.
A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV.
Which of the following adverse effects should the nurse monitor for?
Explanation
Hydralazine can causetachycardia(fast heart rate) as a common side effect.
This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.
Choice B is wrong because hydralazine does not causehyperglycemia(high blood sugar).
Hydralazine is not known to affect glucose metabolism or insulin secretion.
Choice C is wrong because hydralazine does not causehypokalemia(low potassium levels).
Hydralazine is not a diuretic and does not increase potassium excretion.
Choice D is wrong because hydralazine does not causeconstipation.Hydralazine can causediarrheaas a common side effect, but not constipation.
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia.
Which of the following outcomes indicates that the therapy is successful?
Explanation
The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.
Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.
Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.
Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.
Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.
A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion.
Which finding should alert the nurse to suspect magnesium toxicity?
Explanation
Respiratory rate of 10 breaths/min.
This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac arrest.
Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.
Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.
The minimum urine output for an adult is 30 mL/hour.
Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity.Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.
A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure.
Which action should the nurse take first?
Explanation
Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.
This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.
Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.
Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.
Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.
A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation.
The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?
Explanation
Headache that does not respond to analgesics.This is a possible sign of postpartum pre-eclampsia, a rare condition that occurs when a woman has high blood pressure and excess protein in her urine soon after childbirth.Postpartum pre-eclampsia can cause seizures and other serious complications if not treated.
Choice B is wrong because breast engorgement and tenderness are normal symptoms of breastfeeding and do not indicate postpartum pre-eclampsia.
Choice C is wrong because lochia rubra with small clots is a normal discharge of blood and tissue from the uterus after delivery and does not indicate postpartum pre-eclampsia.
Choice D is wrong because perineal pain and swelling are common after vaginal delivery and do not indicate postpartum pre-eclampsia.
Normal ranges for blood pressure are below 120/80 mm Hg and for protein in urine are below 150 mg/day.
A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following results should the nurse notify the provider about? (Select all that apply.)
Explanation
The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.
Both of these results should be reported to the provider as they may require intervention.
Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.
Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.
Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.
A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
Which of the following actions should the nurse take before giving the medication? (Select all that apply.)
Explanation
The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.
• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels.The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.
• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia.Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.
The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.
• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia.Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.
The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.
• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia.Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.
The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.
• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia.The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.
A nurse is educating a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously about the possible side effects of the medication.
Which of the following statements should the nurse include in the teaching?
Explanation
“You may feel warm and flushed while receiving this medication.” This is a common side effect of magnesium sulfate therapy, which is used to prevent seizures in women with severe pre-eclampsia.Magnesium sulfate can also help prolong a pregnancy for up to two days by relaxing the uterus.
Choice B is wrong because magnesium sulfate can cause fluid retention and swelling, not dehydration.Choice C is wrong because magnesium sulfate can cause drowsiness and lethargy, not insomnia and restlessness.Choice D is wrong because magnesium sulfate can cause decreased blood pressure and heart rate, not inflammation and infection at the infusion site.
Normal ranges for blood pressure are below 140/90 mm Hg, for platelet count are 150,000 to 450,000 per microliter of blood, and for protein in urine are less than 300 milligrams per day.
(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate.
Which of the following values should the nurse report to the provider? (Select all that apply.)
Explanation
The correct answer is A and B. A. Serum magnesium level of 8 mg/dL
This statement is correct because a serum magnesium level of 8 mg/dL (6.6 mmol/L) is within the therapeutic range for eclampsia treatment, which is 3.5 to 7 mEq/L (4.2 to 8.4 mg/dL) according to some sources, or 1.5 to 3.5 mmol/L according to others.A serum magnesium level above 8 mEq/L (10 mmol/L) can cause areflexia, respiratory paralysis, and cardiac arrest.
B. Serum calcium level of 7 mg/dL
This statement is correct because a serum calcium level of 7 mg/dL (1.75 mmol/L) is below the normal range of 8.5 to 10.2 mg/dL (2.12 to 2.55 mmol/L), which indicates hypocalcemia.Hypocalcemia is a common side effect of magnesium sulfate therapy, as magnesium competes with calcium for binding sites on plasma proteins and cell membranes, and also inhibits the release of parathyroid hormone.
C. Serum creatinine level of 1.2 mg/dL
This statement is wrong because a serum creatinine level of 1.2 mg/dL (106 umol/L) is within the normal range of 0.6 to 1.3 mg/dL (53 to 115 umol/L) for women.Serum creatinine level reflects kidney function, and renal impairment can affect the clearance of magnesium sulfate and increase the risk of toxicity.
D. Serum potassium level of 3.8 mEq/L
This statement is wrong because a serum potassium level of 3.8 mEq/L (3.8 mmol/L) is within the normal range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L) for adults.Serum potassium level reflects electrolyte balance, and hypokalemia or hyperkalemia can affect cardiac function and muscle contraction.
E. Serum sodium level of 140 mEq/L
This statement is wrong because a serum sodium level of 140 mEq/L (140 mmol/L) is within the normal range of 135 to 145 mEq/L (135 to 145 mmol/L) for adults.Serum sodium level reflects fluid balance, and hyponatremia or hypernatremia can affect brain function and blood pressure.
A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL.
Which of the following medications should the nurse have available as an antidote?
Explanation
Calcium gluconate is the antidote for magnesium sulfate overdose.Magnesium sulfate blocks calcium, so calcium gluconate can reverse the effect of an overdose.
The other choices are not antidotes for magnesium sulfate.Choice A, naloxone, is the antidote for narcotics or opioid overdose.Choice B, flumazenil, is the antidote for benzodiazepine overdose.Choice D, protamine sulfate, is the antidote for heparin overdose.The normal range of magnesium level is 1.5 to 2.5 mEq/L, so a level of 10 mg/dL indicates toxicity.
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia.
Which of the following findings indicates a therapeutic response?
Explanation
Absence of seizures indicates a therapeutic response to magnesium sulfate therapy for a client with eclampsia.Magnesium sulfate is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Magnesium sulfate may act as a vasodilator, an anticonvulsant, and a protector of the blood-brain barrier.
Choice B is wrong because a decrease in urine output may indicate renal impairment, which is a complication of preeclampsia and eclampsia.
Choice C is wrong because an increase in deep tendon reflexes may indicate hyperreflexia, which is a sign of increased neuromuscular irritability and a risk factor for seizures.
Choice D is wrong because an increase in respiratory rate may indicate respiratory distress, which can be caused by pulmonary edema, another complication of preeclampsia and eclampsia.
Normal ranges for urine output are 0.5 to 1 mL/kg/hour, for deep tendon reflexes are 1+ to 2+, and for respiratory rate are 12 to 20 breaths per minute.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion.
Which of the following findings should the nurse identify as an indication of magnesium sulfate toxicity?
Explanation
Urinary output of 100 mL in 4 hr is an indication of magnesium sulfate toxicity.Magnesium sulfate is used to prevent seizures in women with severe preeclampsia or eclampsia.Taking too much magnesium can be life-threatening to both mother and child.
Choice B is wrong because
Choice C is wrong because patellar reflex of +2 is normal and not a sign of toxicity.Loss of deep tendon reflexes can occur with magnesium overdose.
Choice D is wrong because serum magnesium level of 4 mEq/L is normal and not a sign of toxicity.Toxic levels are usually above 8 mEq/L.
A nurse is caring for a client who has eclampsia and is receiving magnesium sulfate and hydralazine.
The client’s blood pressure is 150/90 mmHg, pulse is 88/min, respirations are 18/min, and oxygen saturation is 97%.
The nurse notes that the client’s deep tendon reflexes are absent.
Which of the following actions should the nurse take?
Explanation
Stop the magnesium sulfate infusion.
The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.
Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.
The nurse should stop the infusion and monitor the client’s vital signs and neurological status.
Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.
The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.
Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.
It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.
Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.
The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.
Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.
A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin.
Which of the following findings should the nurse report to the provider immediately?
Explanation
Epigastric pain and nausea.This is because epigastric pain and nausea are signs of severe preeclampsia that indicate liver involvement and possible hepatic rupture.
This is a medical emergency that requires immediate intervention to prevent maternal and fetal complications.
Choice A is wrong because contractions lasting 90 seconds and occurring every 2 minutes are normal during labor induction with oxytocin and do not indicate severe preeclampsia.
Choice B is wrong because fetal heart rate baseline of 140/min with moderate variability is a reassuring sign of fetal well-being and does not indicate severe preeclampsia.
Choice C is wrong because cervical dilation of 4 cm and effacement of 50% are normal findings during labor induction and do not indicate severe preeclampsia.
A nurse is monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate infusion.
What is the antidote for magnesium sulfate toxicity?
Explanation
Calcium gluconate is the antidote for magnesium sulfate toxicity because it reverses the effects of magnesium on the neuromuscular and cardiovascular systems.
Magnesium sulfate can cause respiratory depression, hypotension, bradycardia, and cardiac arrest in high doses.
Choice B. Naloxone is wrong because it is the antidote for opioid overdose, not magnesium sulfate toxicity.
Naloxone blocks the opioid receptors and restores breathing and consciousness.
Choice C. Flumazenil is wrong because it is the antidote for benzodiazepine overdose, not magnesium sulfate toxicity.
Flumazenil binds to the benzodiazepine receptors and reverses the sedative and hypnotic effects.
Choice D. Protamine sulfate is wrong because it is the antidote for heparin overdose, not magnesium sulfate toxicity.
Protamine sulfate neutralizes the anticoagulant effect of heparin and prevents bleeding.
Normal ranges for magnesium are 1.5 to 2.5 mEq/L or 0.75 to 1.25 mmol/L.
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia.
What clinical indicator would suggest that the therapy is successful?
Explanation
Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Seizures are a sign of eclampsia, a severe form of preeclampsia that can be life-threatening.
Therefore, if the therapy is successful, the woman should not have any seizures.
Choice B.Absence of proteinuria is wrong because proteinuria, or excess protein in urine, is a possible sign of preeclampsia, not eclampsia.
Proteinuria may not disappear even after magnesium sulfate therapy.
Choice C.Absence of edema is wrong because edema, or swelling, is a common symptom of pregnancy and may not be related to preeclampsia or eclampsia.
Edema may not disappear even after magnesium sulfate therapy.
Choice D.Absence of headache is wrong because headache is a symptom of preeclampsia, not eclampsia.
Headache may not disappear even after magnesium sulfate therapy.
Normal ranges for blood pressure are below 140/90 mm Hg and for protein in urine are below 300 mg per 24 hours.
A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.
What nursing interventions are appropriate for this client? Select all that apply.
Explanation
The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction.Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure.The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.
Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity.Corticosteroids may worsen the liver function and increase the risk of infection.
Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome.Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.
Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome.The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible.Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.
A nurse is caring for a client who is at 28 weeks of gestation and has a blood pressure of 160/100 mm Hg.
The nurse should anticipate a prescription for which of the following medications?
Explanation
Labetalol is an antihypertensive drug that can lower blood pressure in pregnant women with preeclampsia.Preeclampsia is a condition that causes high blood pressure and proteinuria after 20 weeks of gestation.
Choice A is wrong because hydralazine is not recommended as a first-line treatment for preeclampsia due to its potential adverse effects on maternal and fetal outcomes.
Choice B is wrong because nifedipine is not licensed for use in pregnancy and may interact with magnesium sulfate, which is an anticonvulsant medication used to prevent or treat seizures in severe preeclampsia.
Choice D is wrong because methyldopa is not effective for acute blood pressure control and may cause adverse effects such as depression, sedation, and hemolytic anemia.
A nurse is reviewing the discharge instructions for a client who had severe preeclampsia and delivered her baby at 34 weeks of gestation by cesarean birth.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery.The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia.Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia.The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
A nurse is evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate.
Which of the following findings should the nurse report to the provider as a sign of fetal compromise?
Explanation
Oligohydramnios on ultrasound.Oligohydramnios is a condition where the amniotic fluid volume is less than expected for gestational age.It can be a sign of fetal compromise due to various causes, such as renal abnormalities, placental insufficiency, premature rupture of membranes, or chromosomal anomalies.Oligohydramnios can lead to complications such as fetal deformities, preterm birth, infection, or stillbirth.
Choice A is wrong because a fetal heart rate of 140 beats/min is within the normal range for most of pregnancy.
Choice B is wrong because fetal movement of 10 times in an hour is also within the normal range and indicates fetal well-being.
Choice D is wrong because a reactive nonstress test is a reassuring sign that the fetus is not hypoxic or stressed.
Normal ranges:
• Amniotic fluid index (AFI): 5-25 cm
• Fetal heart rate: 110-160 beats/min
• Fetal movement: at least 10 movements in 2 hours
• Nonstress test: at least two accelerations of fetal heart rate of 15 beats/min for 15 seconds or more in 20 minutes
Introduction
A nurse is caring for a client with pre-eclampsia who is receiving magnesium sulfate.
What is the rationale for administering this medication?
Explanation
To prevent seizures.Magnesium sulfate is given to reduce central nervous system irritability and prevent seizures in clients with preeclampsia.Preeclampsia is a hypertensive disorder that occurs after 20 weeks of gestation and is characterized by elevated blood pressure, proteinuria, edema, headache, epigastric pain, and vision changes.
Choice B is wrong because magnesium sulfate does not lower blood pressure.Some antihypertensive drugs might be given to manage blood pressure in clients with preeclampsia.
Choice C is wrong because magnesium sulfate does not increase urine output.In fact, it can cause urinary retention and oliguria as adverse effects.
Choice D is wrong because magnesium sulfate does not promote fetal lung maturity.
It is given to prevent maternal complications, not fetal ones.Corticosteroids might be given to promote fetal lung maturity if delivery is anticipated before 34 weeks of gestation.
A nurse is assessing a client with severe pre-eclampsia who reports a headache and blurred vision.
What other sign or symptom would indicate a worsening of the condition?
Explanation
Epigastric pain is a sign of worsening pre-eclampsia that indicates liver damage.It can also be associated with HELLP syndrome, a severe complication of pre-eclampsia that involves hemolysis, elevated liver enzymes and low platelet count.
Choice B is wrong because facial edema is a common symptom of pregnancy and not specific to pre-eclampsia.
Choice C is wrong because proteinuria is a diagnostic criterion for pre-eclampsia, but not a sign of worsening condition.
Choice D is wrong because brisk reflexes are a normal finding in pregnancy and do not indicate pre-eclampsia severity.
Normal ranges for blood pressure are below 140/90 mmHg, and for proteinuria are less than 300 mg in 24-hour urine collection.
A nurse is teaching a client with mild pre-eclampsia about the signs and symptoms that she should report to the health care provider.
Which of the following should the nurse include? (Select all that apply)
Explanation
The correct answer is choice A and B.Sudden weight gain and decreased fetal movement are signs of pre-eclampsia, a condition that develops in pregnant women and is marked by high blood pressure and presence of proteins in urine.Pre-eclampsia can affect the blood supply to the placenta and the growth of the baby.
Choice C is wrong because vaginal bleeding is not a symptom of pre-eclampsia, but it may indicate other problems such as placental abruption or miscarriage.
Choice D is wrong because nausea and vomiting are not specific symptoms of pre-eclampsia, but they may occur in some cases.However, excessive vomiting and nausea may be a sign of severe pre-eclampsia.
A nurse is preparing to administer an antihypertensive medication to a client with pre-eclampsia.
What is the goal of pharmacological therapy for this condition?
Explanation
To prevent blood pressure from exceeding 160/110 mmHg.The goal of pharmacological therapy for pre-eclampsia is to prevent severe hypertension that can lead to complications such as stroke, kidney failure, or placental abruption.
Choice A is wrong because maintaining blood pressure below 140/90 mmHg is the target for normal hypertension, not pre-eclampsia.
Choice B is wrong because reducing blood pressure by 25% within one hour is too rapid and can compromise blood flow to the placenta and the fetus.
Choice C is wrong because keeping diastolic blood pressure between 80 and 100 mmHg is not specific enough and does not account for the systolic blood pressure, which is also important.
A nurse is reviewing the laboratory results of a client with pre-eclampsia.
Which of the following findings would indicate a risk of disseminated intravascular coagulation (DIC)?
Explanation
Decreased fibrinogen level.This indicates that the client has a risk of disseminated intravascular coagulation (DIC), which is a condition where the blood clots abnormally and causes bleeding in various organs.Fibrinogen is a protein that is essential for blood clotting, and a low level means that the clotting factors are being consumed faster than they can be produced.
Choice A is wrong because elevated platelet count is not a sign of DIC, but rather of normal pregnancy or other conditions that cause thrombocytosis.Platelets are blood cells that help form clots, and a high count means that there is an increased production or decreased destruction of platelets.
Choice C is wrong because increased prothrombin time (PT) is not a specific sign of DIC, but rather of any condition that affects the extrinsic pathway of coagulation.PT measures how long it takes for the blood to clot by adding tissue factor, which activates factor VII.A prolonged PT means that there is a deficiency or dysfunction of factor VII or other factors in the common pathway (X, V, II, I).
Choice D is wrong because reduced partial thromboplastin time (PTT) is not a sign of DIC, but rather of hypercoagulable states or antiphospholipid syndrome.PTT measures how long it takes for the blood to clot by adding phospholipids and an activator, which activate factor XII.A shortened PTT means that there is an increased activity or presence of factor XII or other factors in the intrinsic or common pathway.
Risk Factors
A nurse is reviewing the medical history of a client who is 32 weeks pregnant and has mild preeclampsia.
Which of the following factors in the client’s history increases her risk for developing this condition? Select all that apply.
Explanation
The correct answer is choices B, C, D and E.These are all factors that increase the risk of developing preeclampsia according to various sources.
Choice A is wrong because maternal age of 37 years old is not a risk factor for preeclampsia by itself.However, advanced maternal age (over 40) is associated with a higher risk.
Some of the other risk factors for preeclampsia that are not mentioned in the question are:
• First pregnancy with current partner
• Family history of preeclampsia
• African American ethnicity
• History of certain health conditions, such as migraines, diabetes, rheumatoid arthritis, lupus, scleroderma, urinary tract infections, gum disease, polycystic ovary syndrome, multiple sclerosis, gestational diabetes, and sickle cell disease
• Pregnancy resulting from egg donation, donor insemination, or in vitro fertilization
Normal ranges for blood pressure and proteinuria in pregnancy are:
• Blood pressure: less than 140/90 mm Hg
• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL in a random urine sample
A nurse is caring for a client who is 36 weeks pregnant and has severe preeclampsia.
The client reports having a severe headache and blurred vision.
The nurse should recognize that these symptoms indicate which of the following complications?
Explanation
Cerebral edema.This is because severe headache and blurred vision are signs of increased intracranial pressure due to swelling of the brain, which can occur in severe preeclampsia.Cerebral edema is a serious complication that can lead to seizures, stroke or death.
Choice A.Pulmonary edema is wrong because it would cause shortness of breath, coughing and chest pain, not headache and blurred vision.
Choice C.Placental abruption is wrong because it would cause abdominal pain, vaginal bleeding and uterine tenderness, not headache and blurred vision.
Choice D.Hepatic rupture is wrong because it would cause epigastric or right upper quadrant pain, nausea and vomiting, not headache and blurred vision.Hepatic rupture is also a rare complication of preeclampsia.
A nurse is preparing to administer magnesium sulfate IV to a client who is 38 weeks pregnant and has eclampsia.
What is the main purpose of this medication for this client?
Explanation
To prevent seizures.Magnesium sulfate is a medication that is used to relax the uterus and prevent seizures in clients with preeclampsia or eclampsia.
It does not lower the blood pressure, induce labor, or increase urine output.
Choice A is wrong because magnesium sulfate does not lower the blood pressure.Other medications, such as labetalol or hydralazine, are used to treat hypertension in preeclampsia.
Choice C is wrong because magnesium sulfate does not induce labor.In fact, it may delay labor by inhibiting uterine contractions.
Choice D is wrong because magnesium sulfate does not increase urine output.It may cause fluid retention and edema, which are signs of magnesium toxicity.The nurse should monitor the client’s urine output, respiratory rate, deep tendon reflexes, and serum magnesium levels while on magnesium sulfate therapy.
A nurse is monitoring a client who is 34 weeks pregnant and has mild preeclampsia.
Which of the following laboratory tests should the nurse review to assess for end-organ damage in this client?
Explanation
Liver enzymes and platelets. The nurse should review these laboratory tests to assess for end-organ damage in a client with mild preeclampsia because they indicate the status of the liver and the coagulation system, which are often affected by this condition.
Choice A is wrong because hemoglobin and hematocrit are not specific indicators of end-organ damage in preeclampsia. They may be elevated due to hemoconcentration from fluid retention or decreased due to hemolysis.
Choice C is wrong because blood glucose and ketones are not related to preeclampsia. They are more relevant for gestational diabetes mellitus, which is a different complication of pregnancy.
Choice D is wrong because creatinine and blood urea nitrogen are not the most sensitive markers of end-organ damage in preeclampsia. They may be elevated due to renal impairment, but proteinuria is a more classic sign of preeclampsia.
Normal ranges for liver enzymes and platelets are:
• AST: 10-40 U/L
• ALT: 7-56 U/L
• ALP: 44-147 U/L
• LDH: 140-280 U/L
• Platelets: 150,000-400,000/mm3
Liver enzymes and platelets.The nurse should review these laboratory tests to assess for end-organ damage in a client with mild preeclampsia because they indicate the status of the liver and the coagulation system, which are often affected by this condition.
Choice A is wrong because hemoglobin and hematocrit are not specific indicators of end-organ damage in preeclampsia.They may be elevated due to hemoconcentration from fluid retention or decreased due to hemolysis.
Choice C is wrong because blood glucose and ketones are not related to preeclampsia.They are more relevant for gestational diabetes mellitus, which is a different complication of pregnancy.
Choice D is wrong because creatinine and blood urea nitrogen are not the most sensitive markers of end-organ damage in preeclampsia.They may be elevated due to renal impairment, but proteinuria is a more classic sign of preeclampsia.
Normal ranges for liver enzymes and platelets are:
• AST: 10-40 U/L
• ALT: 7-56 U/L
• ALP: 44-147 U/L
• LDH: 140-280 U/L
• Platelets: 150,000-400,000/mm3
A nurse is teaching a client who is 28 weeks pregnant and has gestational hypertension about the signs and symptoms of preeclampsia.
Which of the following statements by the client indicates an understanding of the teaching?
Explanation
The client should report any changes in the baby’s movements to the doctor, as this could indicate fetal distress due to reduced blood flow to the placenta.
Choice A is wrong because swelling in the hands and feet is a common symptom of pregnancy and not necessarily a sign of preeclampsia.
However, if the swelling is sudden or severe, the client should seek medical attention.
Choice B is wrong because checking blood pressure at home every day is not a reliable way to monitor for preeclampsia.
Blood pressure can vary throughout the day and may be affected by other factors such as stress, activity, or medication.The client should have regular prenatal visits with a health care provider who can measure blood pressure and perform other tests to detect preeclampsia.
Choice D is wrong because weighing oneself every week and reporting any sudden weight gain is not enough to prevent or diagnose preeclampsia.
Weight gain during pregnancy can also be influenced by fluid retention, diet, or other factors.The client should also look out for other signs and symptoms of preeclampsia, such as severe headaches, vision changes, abdominal pain, or reduced urine output.
Clinical Features
A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands.
Which intervention is the priority for this client?
Explanation
Encourage bed rest in a left lateral position.
This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus.The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.
Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.
Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia.Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.
A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands.
Which intervention is the priority for this client?
Explanation
This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus.The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.
Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.
Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia.Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.
A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate.
Which finding would indicate a therapeutic level of magnesium sulfate?
Explanation
This indicates a therapeutic level of magnesium sulfate for a client with severe pre-eclampsia who is receiving magnesium sulfate.According to some sources, the effective therapeutic serum magnesium level is 1.8–3.0 mmol/L, which corresponds to 4.2–7 mg/dL or 3.5–7 mEq/L.
Choice B is wrong because serum calcium level of 8.5 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice C is wrong because serum creatinine level of 1.2 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice D is wrong because serum potassium level of 3.5 mEq/L is at the lower end of the normal range and does not indicate the effect of magnesium sulfate.
A nurse is preparing to administer hydralazine to a client with pre-eclampsia who has a blood pressure of 180/110 mmHg.
What is the rationale for using this medication?
Explanation
This is the rationale for using this medication in a client with pre-eclampsia who has a blood pressure of 180/110 mmHg.High blood pressure in pre-eclampsia can cause damage to the kidneys, liver, brain, and other organs, and can also increase the risk of complications for the baby.
Therefore, lowering blood pressure with hydralazine can help prevent or reduce these adverse outcomes.
Choice A is wrong because hydralazine does not reduce cerebral edema or prevent seizures.These are symptoms of eclampsia, a more severe form of pre-eclampsia that requires different treatment.
Choice B is wrong because hydralazine does not increase uteroplacental perfusion or fetal oxygenation.These are affected by other factors such as the placental function, maternal position, and fetal well-being.
Choice C is wrong because hydralazine does not decrease proteinuria or prevent renal damage.
Proteinuria is a sign of kidney impairment that occurs in pre-eclampsia, but it is not directly affected by hydralazine.Renal damage can be prevented by controlling blood pressure and avoiding nephrotoxic drugs.
A nurse is assessing a client with pre-eclampsia who is receiving oxytocin for labor induction.
Which finding would alert the nurse to suspect that the client is developing HELLP syndrome?
Explanation
This is because HELLP syndrome is a complication of pregnancy that affects the liver and blood clotting.It can cause liver damage, bleeding problems, and high blood pressure.Epigastric pain or right upper quadrant pain is a sign of liver injury or rupture.
Choice B is wrong because blurred vision or flashes of light are symptoms of preeclampsia, not HELLP syndrome.
Preeclampsia is a condition that causes high blood pressure and protein in the urine during pregnancy.It can lead to HELLP syndrome, but not all women with preeclampsia develop HELLP syndrome.
Choice C is wrong because decreased urinary output or oliguria are also symptoms of preeclampsia, not HELLP syndrome.
Oliguria means producing less than 400 mL of urine in 24 hours.It can indicate kidney damage or failure due to high blood pressure or proteinuria.
Choice D is wrong because hyperreflexia or clonus are also symptoms of preeclampsia, not HELLP syndrome.
Hyperreflexia means having exaggerated reflexes, while clonus means having involuntary muscle spasms.
They can indicate nervous system involvement or seizures due to high
A nurse is providing discharge instructions to a client who had pre-eclampsia and delivered a healthy baby.
Which statement by the client indicates a need for further teaching?