1. In reviewing Jennie’s history, the RN is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Jennie’s risk of developing preeclampsia? (Select all)
-Preexisting medical or genetic condition, such as Factor V Leiden
2. To accurately assess this client’s condition, what information from the prenatal record is most important for the RN to obtain?
Prenatal blood pressure readings.
3. What is the pathophysiology responsible for Jennie’s complaint of a pounding headache and the elevated DTRs?
As fluid leaks into extravascular spaces, organ edema, as well as peripheral edema, occurs. This, along with cortical brain spasms, causes headache, increased DTRs, and clonus.
4. Jennie’s sister is concerned about the edema in her sister’s face and hands. She asks the RN if the (HCP) will prescribe some of “those water pills” (diuretics) to help get rid of the excess fluid. Which response by the RN is correct?
“Let me explain to you about the effect of diuretics on pregnancy.”
Diuretics decrease blood flow to the placenta by decreasing blood volume. For a client with preeclampsia, this is particularly dangerous because the disease has already caused a volume deficit. Diuretics also disrupt normal electrolyte balance and stress kidneys.
5. After the RN establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000mL D5LR. The order from the HCP is oxytocin 2mU/min to augment labor. Calculate the drip rate for the oxytocin. (Whole number)
1/1000 x 2mu/1hr=
0.10 x 60 min=
6. While the RN is awaiting the lab results to determin if Jennie has elevatioin in liver function, diminished kidney function, or altered coagulopathies, which question should the RN ask Jennie? (Select all)
-“Do you have a headache?”
-“Do you have blurry vision?”
-“Do you have epigastric pain?”
-“Do you have shortness of breath or chest discomfort?”
7. Which technique should the RN use when evaluating Jennie’s blood pressure while Jennie is on bedrest?
Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.
Lateral position supports placental perfusion.
8. When performing a nonstress test, the RN will be assessing for which parameters?
Acceleration of the fetal heart rate in response to fetal movement.
The basis for the nonstress test is that the normal fetus with intact CNS will respond to fetal movements with an increased HR and episodic accelerations.
A reactive test is one in which the fetus displays at least 2 accelerations of 15 beats/min that last for 15 seconds in a 20 minute period, in the presence of a normal baseline rate and moderate variability.
9. If Jennie had HELLP syndrome, which lab results would the RN expect to see?
Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, platelet count 3
10. The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced RN?
A 35-year-old gravida 3, para 2, with HELLP syndrome
A patient with HELLP is at high risk for morbidity and mortality. This syndrome occurs in only 2-12% of patients with severe preeclampsia. Commonly seen in older, white, multiparous patients.
11. What is the primary action of magnesium sulfate when given in preeclampsia?
A CNS depressant.
Magnesium sulfate depresses the CNS by inferring with the neuromuscular junction. It is given to prevent or control eclamptic seizures.
12. Since Jennie is receiving magnesium sulfate and oxytocin, the RN should make what adjustments to the oxytocin?
No adjustment to the oxytocin induction
13. Which assessment finding would indicate to the RN that a client is experiencing magnesium sulfate toxicity?
Respiratory rate of <12 breaths/min, and absent DTRs
14. The RN asks Jennie if the HCP has discussed the labor and delivery process, potential complications, and the management of those complications with her and if she understands them. Jennie replies “I think so,” and then asks for a pen. Which action should the RN take?
Ask Jennie to explain what she understands about the procedures
15. Jennie’s sister offers to sign the consent forms for her because Jennie is so young and just isn’t feeling well right now. Which response by the RN is correct?
“Jennie should sign the consent forms herself since she is the one receiving the care.”
16. Jennie asks why the magnesium sulfate was increased. What explanation should the RN provide?
The magnesium is being excreted through the kidneys.
Magnesium is cleared by the kidneys. Jennie’s kidneys are working well, and thus the magnesium level is not up to therapeutic range because it is being excreted.
17. When the RN evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change?
The fetus has a magnesium level equal to the mother’s, causing the fetus to be somewhat sedated.
Magnesium sulfate crosses the placenta.
18. At 0930 Jennie’s sister rings the call bell and yells, “Come quickly, Jennie is shaking all over.” The RN determines that Jennie is experiencing an eclamptic seizure. Which nursing intervention takes priority?
Turn Jennie onto her side and place a pillow behind her to stabilize the position.
Aspiration is the leading cause of maternal morbidity and mortality after eclampsia. Turning her will ensure that an airway is maintained, aspiration is minimized, and supine hypotension is prevented.
19. The RN recognizes what type of periodic fetal heart rate change that is occurring?
Late decelerations are caused by uteroplacental insufficiency. Late decelerations are characterized by a gradual decrease from the baseline that begins after the contraction has started and does not return to baseline until after the contraction ends.
Persistent late decelerations usually indicate fetal hypoxemia and can progress to hypoxia and academia. In this case, the late decelerations stem from the eclamptic seizure.
20. What should the RN do next to ensure intrauterine resuscitation?
Implement a prescribed fluid bolus to improve maternal blood volume, thereby improving blood flow and oxygenation to the fetus.
21. What medication should the RN have readily available as an antidote for magnesium sulfate?
Calcium gluconate is the antidote for magnesium sulfate, given slow IV push over at least 3 minutes. Monitor the patient for cardiac reactions such as dysrhythmias, bradycardia, and ventricular fibrillation.
22. For which complication is Jennie most at risk following the epidural with a local anesthestic, such as bupivacaine or ropivacaine?
Occurs as a result of the sympathetic blockade. It is common after an epidural if the mother is not adequately pre-hydrated or has impaired fluid volume. It can be prevented by adequate pre-load.
23. At 1130 Jennie complains of rectal pressure and an urge to push. The RN reviews the proper pushing technique with Jennie and her partner. What should the RN tell Jennie?
When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides.
Exhalation while pushing and taking breaths in between pushes helps to maintain adequate oxygenation to the mother and fetus.
24. The NICU RN anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate?
Hyporeflexia and decreased respirations.
Crosses the placenta. Hypermagnesemia can be treated with calcium, cleared through the kidneys.
25. Jennie remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released Jennie from the postanesthesia care unit. Which room and nursing staff assignments should be made for Jennie?
Move Jennie to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her.
Patient remains at risk for seizures. Magnesium is continued for at least 12-24 hours. Close assessment, frequent vitals, reflex checks, and I&O measures are necessary.
Patient is also at risk for postpartum hemorrhage due to magnesium sulfate infusions (relaxes smooth muscle).
26. Jennie’s partner asks if some friends can come and watch television with him now that the baby has been born. Which response by the RN is most appropriate?
“Your partner is still at risk for complications, so visitors are limited to family members, and only for a short period of time.”
27. The RN is aware that which medication is safest for Jennie if a second drug is needed to treat postpartum hemorrhage?