1. Ir 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 that Apply.)
--Preexisting medical or genetic condition, such as Factor V Leiden.
Toxemia - is an old term for preeclampsia that some clients may still use.
Reason for preeclampsia are unknown, but research shows that preexisting medical conditions and genetic conditions put the client at higher risk for preeclampsia.
Nulliparity - first pregnancy places a client at higher risk preeclampsia than multiparty with the same partner.
no definite cause, but the main pathophysiology is poor perfusion as a result of arteriolar vasospasm. Function in organs such as placenta, liver, brain, and kidneys can be depressed as much as 40-60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen => generalize edema.
Preeclampsia develops after 20 weeks gestation id a previously normotensive women.
SS: elevated blood pressure, may also develop proteinuria (no longer considered a diagnosis measurement), generalize edema of face, hands, and abdomen - not responsive to 12 bedrest.
Preeclampsia progresses along a continuum form mild to severe preeclampsia, HELLP syndrome, or eclampsia. A client may present to the labor unit anywhere along that continuum.
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.
BP (138/88) - indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading f 140/90 taken on 2 occasions 6 hours apart.
Blood pressure usually remains the same during the 1st semester.
Both systolic and diastolic then decrease gradually up to 20 week gestation.
At 20 weeks of gestation, the blood pressure begins to gradually increase and return to 1st trimester levels at term.
3.What is the pathophysiology responsible for Jennie's complaint of a pounding headache and the elevated DTRs?
As fluid leaks into the extravascular spaces,organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increases DTRs, and clonus
4. Which response by the RN is correct?
"Let me explain to you about the effects of diuretics on pregnancy."
Diuretics decrease blood flow to the placenta by decreasing blood flow. In the case of the preeclamptic client, this is particularly dangerous because the disease has already caused a volume deficit. In addition, the diuretics disrupt normal electrolyte balance and stress kidneys that are already compromised by preeclampsia. The only time they are used is if the preeclamptic client also had a heart failure, but this client has no symptoms of HF.
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.
*note: Calculate ml/hr, not drops/min
20 units = 20, 000 mu
6. While the RN is awaiting the lab results to determine if Jennie has elevation in her liver function, diminished kidney function, or altered coagulopathies, which question should the RN ask Jennie? (Select all that apply)
--"Do you have a headache?"
--"Do you have blurry vision?"
--"Do you have epigastric pain?"
--"Do you have shortness of breath or chest discomfort?"
Central nervous system (CNS) changes such as severe headache, blurred vision, scotoma (spots before eyes), and photophobia indicate a worsening condition.
7. Which technique should the RN use when evaluation 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.
The lateral position supports placenta perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the BP should be taken in that arm. this more closely approximates arterial pressure. Using the arm on the opposite (upper) side will falsely reduce the measurement.
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 basic of non stress test is that normal fetus with an intact CNS will response to fetal movements by increasing its HR (episodic accelerations).
A reactive test is one in which the fetus displays at least 2 acce;rations of 15 beats per min that last for 15 s in a 20 min 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
HELLP stands for: hemolysis (H), evidenced by burr cells or an elevated bilirubin level; elevated liver enzymes (EL), evidenced by elevated AST and ALT; and low platelets (LP), evidenced by a platelet count of 3.
10. Which client should be assigned to the most experienced RN?
A 35-year-old gravida 3, para 2, with HELLP syndrome.
This client is the most critical among this group of clients and is at the highest risk for morbidity and mortality. HELLP syndrome occurs in only 2 - 12 % of severely preeclamptic clients. Common seen in older, Caucasian, multiparous clients.
SS: may complain of a general feeling of malaise over several days, have epigastric, to upper abdominal pain, and may experience nausea, and vomiting. BP may be only slightly elevated, or it may even be normal. Proteinuria may be absent. A non-DIC coagulopathy is often associated with HELLP syndrome.
11. What is the primary action of magnesium sulfate when given in preeclampsia?
A CNS depressant.
Magnesium sulfate depressed the CNS by interfering 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 toxicity?
Respiratory rate is <12 and absent DTRs
Both indicate toxicity as does urine output of <30ml/hr.
14. Which action should the RN take?
Ask Jennie to explain what she understands about the procedures.
It is the responsibility of the nurse to ascertain what the client understands about the procedures and the potential risks associated with those procedures.
15. Which response by the RN is correct?
"Jennie should sign the consent forms herself since she is the one receiving the care."
16. What explanation should the RN provide? Magnesium sulfate was increased.
The magnesium is being excreted through the kidneys.
Magnesium is cleared by the kidneys. Jennie's kidneys are working well (average 100 ml/hr since admission). The magnesium level is not up to therapeutic range (4-8 mg/dl) because it is being excreted from the body.
17. 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, the baby will have a magnesium level equal to the mother.
18. 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 an eclamptic seizure. By turning Jennie to a lateral position and using a pillow to hold that position, a patient airway can be maintained, the aspiration of vomitus minimized, and supine hypotension prevented.
19. The RN recognizes what type of periodic fetal heart rate change is occurring?
Late decelerations are caused by uteroplacental insufficiency. Late decelerations are characterized by a gradual decrease form the baseline that begins after the contraction has started and does not return to baseline until after the contraction ends. Persistence late decelerations usually indicate fetal hypoxemia and can process to hypoxia and academia. In Jennie;s case, the decelerations stem form the eclamptic seizure, during which the oxygen supply to the mother and fetus was compromised.
20. What should the RN do next to ensure intrauterine resuscitation?
Implement a prescribed fluid bolus to improve maternal blood volume
A bolus of non dextrose IV fluid (normal saline or RINGER;S LACTATES) will increase the maternal fluid 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. It is given slow IV push over at least 3 mins. The client should be monitored carefully 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 anesthetic, such as bupivacaine or popivacaine?
Hypotension occurs as a result of sympathetic blockade. It is common occurrence after an epidural if the mother is not adequately pre-hydrated or already has an impaired fluid volume.
23. 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.
this method of pushing utilize both instinctive, spontaneous pushing and open- glottis pushing. It is physiologically correct in that it utilizes Ferguson's (the urge to bear down), at which more oxytocin is released from the exterior pituitary to strengthen bearing down contractions.
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.
Magnesium sulfate crosses the placenta, the newborn can develop toxic levels of magnesium. Neonatal hypermagnesemia manifest as hypotonia, and marked decrease in respiratory rate. Hypermegnesemia may be treated with calcium and exchange transfusion with citrates blood and or assisted mechanical ventilation until serum levels are normal. As with the mother magnesium is cleared through the kidneys.
25. 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.
26. 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 short periods of time."
27. The RN recognizes that which medication is safest for Jennie if a second drug is needed to treat postpartum hemorrhage?
Classification ( prostaglandin, oxitocica)
Action: stimulates contraction of the uterus.
This medication, a deviated pf prostaglandin F2 alpha, may be administered intramuscularly, intramyometrially at cesarean birth, or intraabdominally after vaginal birth. This drug may be used with th hypertensive client.