Call for immediate assistance

The Pregnant Client with Miscellaneous Complications

1. Call for immediate assistance

Answers, Rationales, and Test Taking Strategies

The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills. For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.

The Pregnant Client with Preeclampsia or Eclampsia

1.

^{50 mL}

CN: Pharmacological and parenteral therapies; CL: Apply

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2.

3. The two major defi ning characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client’s blood pressure meets the gestational hyper- tension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hyper- tension. The edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. The preeclamptic client will have signifi cant edema in the face and hands. Headaches are signifi cant in pregnancy- induced hypertension but may have other

etiologies. The client’s blood glucose level has no bearing on a preeclampsia diagnosis.

CN: Physiological adaptation;

CL: Analysis

3.

4. The fetus is considered well if it moves more often than 3 times in 1 hour. Daily fetal move- ment counting is part of all high-risk assessments and is a noninvasive, inexpensive method of moni- toring fetal well-being. The health care provider should be notifi ed if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.

CN: Reduction of risk potential;

CL: Evaluation

4.

3. The central nervous system (CNS) func- tioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hyperten- sion or stroke, oxygenation status is compromised and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of second- ary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assess- ment of maternal refl exes, clonus, visual disturbanc- es, and headache give clear evidence of the condi- tion of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system but the less invasive and highly correlated condition of the maternal CNS system in assessing refl exes, maternal headache, visual distur- bances, and clonus is the highest priority. Psycho- social care is a priority and can be accomplished in ways other than having the family remain at the bedside.

CN: Safety and infection control;

CL: Synthesize

5.

3. Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with fi ve or more preg- nancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb at 32 weeks’ gestation with a 1-lb weight gain in the last 2 weeks is within normal limits.

Short stature is not associated with the develop- ment of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced hypertension.

CN: Reduction of risk potential;

CL: Synthesize

6.

4. A weight gain of 2 lb (0.9 kg) in the last week during the third trimester and mild peripheral edema are associated with mild preeclampsia. With severe preeclampsia, peripheral edema is extensive.

Blood pressure readings of 160 mm Hg systolic and 100 mm Hg diastolic on two separate occasions and oliguria (urine output less than 400 mL in 24 hours) are signs of severe preeclampsia. Proteinuria, 3+ to 4+ or more than 5 g in a 24-hour sample, also indi- cates severe preeclampsia. Normal serum creatinine levels range from 0.5 to 1.1 mL/dL. A serum creati- nine concentration of 1.4 mL/dL is greatly elevated, indicating severe preeclampsia.

CN: Physiological adaptation;

CL: Analysis

7.

4. Protein on the urine dipstick with mild preeclampsia should not exceed 1 + and should be followed by a 24-hour urine collection. Oc- casional headache is normal but if these should increase in frequency and change in character, they would need to be further evaluated. Frequent voiding in large amounts is not related to preec- lampsia. 1+ pedal edema is a frequent occurrence in a pregnant client, especially during the later part of pregnancy.

CN: Reduction of risk potential;

CL: Analyze

8.

3. The client with mild preeclampsia is com- monly treated at home with activity restriction. Bed rest for most of the day with the client lying in the left lateral recumbent position is recommended.

This position helps to decrease pressure on the vena cava, thus increasing venous return, circula- tory volume, and renal and placental perfusion.

A decrease in angiotensin II improves renal blood fl ow, lowers blood pressure, and increases diuresis.

Typically, the client is monitored with home visits twice a week. The client usually returns to the clinic

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every 2 weeks until 36 weeks’ gestation. After that time, clinic visits occur at least every week or more often, if needed. The client’s diet needs to be well balanced, with ample protein intake. Fiber intake may need to be increased to prevent complications from prolonged bed rest, such as constipation. If magnesium sulfate is necessary, as in severe preec- lampsia, the drug is usually administered intra- venously, and the client is carefully monitored in the hospital setting because of the possible risk of seizure activity.

CN: Physiological adaptation;

CL: Analysis

9.

1. Congenital anomalies such as hydrocepha- lus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth retardation, and poor placental perfusion are associated with preeclampsia. Abrup- tio placentae occurs because of severe vasoconstric- tion. Intrauterine growth retardation is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction.

CN: Physiological adaptation;

CL: Evaluate

10.

3. Numerous methods have been proposed to record the maternal perceptions of fetal movement or “kick counts.” A commonly used method is the Cardiff count-to-10 method. The client begins count- ing fetal movements at a specifi ed time (e.g., 8:00 a.m.) and notes the time when the 10th movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10 to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement accurately. The client should monitor fetal movements more frequently than 1 time per week. One hour of monitoring each day is adequate.

CN: Reduction of risk potential;

CL: Evaluate

11.

3. For clients with mild preeclampsia, a regular diet with ample protein and calories is rec- ommended. If the client experiences constipation, she should increase the fi ber in her diet, such as by eating raw fruits and vegetables, and increase fl uid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fl uid intake should not be restricted or increased. A high-protein diet is unnecessary.

CN: Basic care and comfort; CL: Apply

12.

1. Severe headache, visual disturbances such as blurred vision, and epigastric pain are associated with the development of severe preec- lampsia and possibly eclampsia. These danger

signs and symptoms must be reported immediately.

Severe headache and visual disturbances are related to severe vasoconstriction and a severe in- crease in blood pressure. Epigastric pain is related to hepatic dysfunction. Ankle edema is common during the third trimester. However, facial edema is associated with increased fl uid retention and the progression from mild to severe preeclampsia.

Increased energy levels are not associated with a progression of the client’s preeclampsia or the de- velopment of complications. In fact, some women report an “energy spurt” before the onset of labor.

Mild backache is a common discomfort of preg- nancy, unrelated to a progression of the client’s preeclampsia. It also may be associated with bed rest when the mattress is not fi rm. Some multipa- rous women have reported a mild backache as a sign of impending labor.

CN: Reduction of risk potential;

CL: Synthesize

13.

2. A client with preeclampsia complaining of a continuous headache for 2 days should be seen by a health care provider immediately. Continuous headache, drowsiness, and mental confusion indi- cate poor cerebral perfusion and are symptoms of se- vere preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Aspirin with codeine may temporarily relieve the client’s headache.

However, this delays immediate treatment, which is crucial. Additionally, pregnant women are advised not to take aspirin at this time because it may cause clotting problems in the neonate. Codeine generally is not prescribed.

CN: Reduction of risk potential;

CL: Synthesize

14.

2. Signs of severe preeclampsia include blood pressure of 160/110 mm Hg or greater mea- sured at two different times at least 6 hours apart, severe blurring of vision or seeing spots in front of the eyes, oliguria, proteinuria of 5 g or greater in a 24-hour specimen, a serum creatinine concentration of 1.2 mL/dL, and a urine specifi c gravity of 1.04 or greater. A blood pressure of 138/94 mm Hg would suggest mild preeclampsia, as would proteinuria of less than 2 g in a 24-hour urine specimen. A weight gain of 1 lb per week in the third trimester is nor- mal. However, a weight gain of 2 lb or more suggests severe preeclampsia.

CN: Physiological adaptation;

CL: Synthesize

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15.

4. The client with severe preeclampsia may develop eclampsia, which is characterized by sei- zures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur.

Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. How- ever, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

CN: Physiological adaptation; CL: Apply

16.

3. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client’s bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women.

Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.

CN: Pharmacological and parenteral therapies; CL: Apply

17.

1. Typical signs of hypermagnesemia include decreased deep tendon refl exes, sweating or a fl ush- ing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity in- creases. The nurse should check the client’s patellar, biceps, and radial refl exes regularly during magne- sium sulfate therapy. Cool skin temperature may re- sult from peripheral vasodilation, but the opposite—

fl ushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia.

Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

CN: Physiological adaptation;

CL: Analyze

18.

2. The only known cure for severe preec- lampsia is delivery of the fetus. In severe cases, labor induction is initiated or a cesarean section is performed. Early diagnosis and careful management are used to control the disease. Medical treatment for severe preeclampsia includes bed rest in a quiet, darkened room, a regular diet, restoration of fl uid and electrolyte balance, sedation and antihyper- tensive medications, usually magnesium sulfate.

Glucocorticoids such as betamethasone are used to enhance fetal lung maturity and are administered at 35 weeks’ gestation or less. Glucocorticoids would

not be indicated with this client who is 37 weeks’

gestation. Phenytoin (Dilantin) may be used to control seizures in preclampsia but is not a fi rst line drug and does not reduce the blood pressure as- sociated with preeclampsia. During pregnancy, the drug is usually not prescribed because of the risk for fetal malformations. Although reduction of fl uid retention may make the client more comfortable, thiazide diuretics can result in serious sodium and potassium depletion, hemorrhagic pancreatitis, and neonatal thrombocytopenia.

CN: Reduction of risk potential;

CL: Create

19.

4. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to deliver the in- fant safely. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney dam- age, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased.

Sedation and decreased refl ex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

CN: Physiological adaptation; CL: Create

20.

1, 3, 5, 6, 7. The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromus- cular transmissions and decreasing the amount of acetylcholine liberated. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (RPM).

Rates at 12 RPM or lower are associated with respiratory depression and are seen with magne- sium toxicity. Renal compromise is identifi ed with a urinary output of <30 mL per hour. A fetal heart rate that is maintained within the 112–160 range is desired without later or variable decelerations.

Deep tendon refl exes that are not diminished or exaggerated are a desired outcome. The therapeu- tic magnesium sulfate level of 5–8 mg/dL is to be maintained. Clonus and hyper-refl exivity are not desired outcomes.

CN: Pharmacological and parenteral therapies; CL: Evaluate

21.

1. A respiratory rate of 12 breaths/minute suggests potential respiratory depression, an adverse effect of magnesium sulfate therapy. The medication must be stopped and the physician should be noti- fi ed immediately. A patellar refl ex of +2 is normal.

Absence of a patellar refl ex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg

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would be a common fi nding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client receiving intravenous magne- sium sulfate. Oliguria is more common.

CN: Pharmacological and parenteral therapies; CL: Synthesize

22.

3. If a client begins to have a seizure, the fi rst action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring.

An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained.

CN: Reduction of risk potential;

CL: Synthesize

23.

1. One of the most common adverse effects of the drug hydralazine (Apresoline) is tachycar- dia. Therefore, the nurse should assess the client’s heart rate and pulse. Hydralazine acts to lower blood pressure by peripheral dilation without interfering with placental circulation. Bradyp- nea and polyuria are usually not associated with hydralazine use. Dysphagia is not a typical adverse effect of hydralazine.

CN: Pharmacological and parenteral therapies; CL: Analyze

24.

4. These fi ndings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements.

CN: Physiological adaptation; CL: Apply

25.

3. Epigastric pain or acute right upper quad- rant pain is associated with the development of eclampsia and an impending seizure; this is thought to be related to liver ischemia. Decreased contrac- tion intensity is unrelated to the severity of the preeclampsia. Typically, the client’s temperature increases because of increased cerebral pressure.

A decrease in temperature is unrelated to an im- pending seizure. Hyporefl exia is not associated with an impending seizure. Typically, the client would exhibit hyperrefl exia.

CN: Physiological adaptation;

CL: Analyze

26.

4. After an eclamptic seizure, the client com- monly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor, because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial fl ushing is not common unless it is

caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

CN: Physiological adaptation;

CL: Analyze

27.

1. After an eclamptic seizure, the client is at risk for abruptio placentae due to severe vasocon- striction resulting in hemorrhage into the decidua basalis. Abruptio placentae is manifested by a board-like abdomen and nonreassuring fetal heart rate tracing. Transverse lie or shoulder presenta- tion, placenta accreta, and uterine atony are not related to eclampsia. Causes of a transverse lie may include relaxation of the abdominal wall secondary to grand multiparity, preterm fetus, placenta previa, abnormal uterus, contracted pelvis, and excessive amniotic fl uid. Placenta accreta, a rare phenomenon, refers to a condition in which the placenta abnor- mally adheres to the uterine lining. Uterine atony, or relaxed uterus, may occur after delivery, leading to postpartum hemorrhage.

CN: Physiological adaptation;

CL: Analyze

28.

2. The normal value of an LDH in a non-preg- nant person is 45 to 90 units/L. LDH elevations in- dicate tissue destruction that can occur with HELLP syndrome. This platelet range is in the normal range of 150,000 to 400,000/mm3 and remains unchanged during pregnancy. Uric acid in a non-pregnant woman is 2 to 6.6 mg/dL. AST normal range is 4 to 20 units/L, abnormal levels indicate liver damage.

CN: Reduction of risk potential;

CL: Synthesize

The Pregnant Client with a Chronic Hypertensive Disorder

29.

1. Pregnancy is not the time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant women report that eating more frequent, smaller meals decreases heartburn resulting from the refl ux of acidic secre- tions into the lower esophagus. Pregnant women need adequate hydration (fl uids) and fi ber to pre- vent constipation.

CN: Basic care and comfort; CL: Evaluate

30.

2. Women with chronic hypertension dur- ing pregnancy are at risk for complications such as preeclampsia (about 25%), abruptio placentae, and intrauterine growth retardation, resulting in a small-for-gestational-age infant. There is no

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