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PREECLAMPSIA
1.
In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factors add to Jennie's risk of developing preeclampsia?
A) Molar pregnancy, history of preeclampsia in previous pregnancy.
INCORRECT
While all of these are risk factors for preeclampsia, Jennie has no indications of a molar pregnancy (first trimester vaginal bleeding, size/date discrepancy, or excessive nausea and vomiting), nor has she had any previous pregnancies (gravida 1).
B) Gravidity, familial history.
CORRECT
Jennie is under 17 years of age, is pregnant for the 1st time, and has a sister with a history of toxemia, which is an old term for preeclampsia that some clients may still use.
C) History of pounding headache, low socioeconomic status.
INCORRECT
While age and low socioeconomic status (SES) are risk factors, Jennie's SES is unknown. A pounding headache is a symptom, not a risk factor.
D) Low socioeconomic status (SES), history of pedal edema.
INCORRECT
Although age and low SES are risk factors, this client's SES is unknown. Pedal edema is common in pregnancy after 32-weeks.
2.
To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain?
A) Pattern and number of prenatal visits.
INCORRECT
It is important to have early and consistent prenatal care, but this information will not help in the assessment of this client's condition.
B) Prenatal blood pressure readings.
CORRECT
The client's BP (138/88) is below the guideline that indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of 140/90 taken on two occasions 6 hours apart. However, Jennie's reading is significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal levels, particularly in combination with proteinuria and hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the same during the first trimester. Both systolic and diastolic then decrease gradually up to 20-weeks gestation. At 20 weeks of gestation, the blood pressure begins to gradually increase and return to 1st trimester levels at term.
C) Prepregnancy weight.
INCORRECT
The nurse should compare today's weight to Jennie's most recently obtained previous weight, not to the prepregnancy weight. A weight gain of >2 pounds per week is indicative of mild preeclampsia.
D) Jennie's Rh factor.
INCORRECT
While the Rh factor of the mother is important in determining the need for prophylactic Rh immune globulin (RhoGAM) at 28-weeks and after birth, it is not the most important information at this time. All Rh negative women with negative Coomb's tests are given RhoGam prophylactically at 28-weeks, and then evaluated immediately after birth to determine if another dose of RhoGam is needed.
Pathophysiology of Preeclampsia
There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm. Function in organs such as the placenta, liver, brain, and kidneys can be depressed as much as 40 to 60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen. The edema of preeclampsia is generalized. Virtually all organ systems are affected by this disease, and the mother and fetus suffer increasing risk as the disease progresses.
Preeclampsia develops after 20 weeks gestation in a previously normotensive woman. Elevated blood pressure is frequently the first sign of preeclampsia. The client also develops proteinuria. While no longer considered a diagnostic measurement of preeclampsia, generalized edema of the face, hands, and abdomen that is not responsive to 12 hours of bedrest is often present. Preeclampsia progresses along a continuum from mild to severe preeclampsia, HELLP syndrome, or eclampsia. A client may present to the labor unit anywhere along that continuum.
3.
What is the pathophysiology responsible for Jennie's complaint of a pounding headache and the elevated DTRs?
A) Cerebral edema.
CORRECT
As fluid leaks into the extravascular spaces, organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increased deep tendon reflexes, and clonus.
B) Increased perfusion to the brain.
INCORRECT
The hypovolemia that accompanies preeclampsia decreases perfusion to the major organs.
C) Severe anxiety.
INCORRECT
While Jennie may be very anxious, this is not the pathophysiology involved.
D) Retinal arteriolar spasms.
INCORRECT
These spasms are the cause of blurred vision and scotoma that often accompany worsening of the disease.
Jennie's sister is very concerned about the swelling (edema) in her sister's face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider will prescribe some of "those water pills" (diuretics) to help get rid of the excess fluid.
4.
Which response by the nurse is correct?
A) "That is a very good idea. I will relay it to the healthcare provider when I call."
INCORRECT
Although it is caring to offer to relay family concerns to the healthcare provider, the physician will make the decision on treatment.
B) "I'm sorry, but it is not the family's place to make suggestions about medical treatment."
INCORRECT
While it is not inappropiate for family members to make suggestions, this answer is not sensitive to the sister's desire to help Jennie.
C) "Let me explain to you about the effect of diuretics on pregnancy."
CORRECT
The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood volume. 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 has heart failure, but this client has no symptoms of heart failure.
D) "Have you by any chance given your sister water pills that belong to someone else?"
INCORRECT
This could be construed as hostile and accusatory. If the nurse believes further assessment is warranted, the nurse should ask Jennie about any medication she has taken.
Admission to the Labor and Delivery Unit
At 0630 the nurse calls to report to the healthcare provider, who prescribes the following: admit to labor and delivery, bedrest with bathroom privileges (BRP), IV D5LR at 125 ml/hr, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital signs, and DTRs.
5.
While awaiting the lab results, which nursing intervention has the highest priority?
A) Teach Jennie the rationale for bedrest.
INCORRECT
While this is important, it does not have the highest priority.
B) Monitor Jennie for signs of dehydration.
INCORRECT
This is important because the client is restricted to ice chips only and may already be hypovolemic. However, it is not the highest priority.
C) Educate the client about dietary restrictions.
INCORRECT
Since Jennie is currently taking ice chips only, this is not the most important intervention at this time.
D) Observe Jennie for CNS changes.
CORRECT
Central Nervous System (CNS) changes such as severe headache, blurred vision, scotoma (spots before eyes), and photophobia indicate a worsening condition.
6.
Which technique should the nurse use when evaluating Jennie's blood pressure while she is on bedrest?
A) Have Jennie lay supine and take the blood pressure on the left arm.
INCORRECT
The pregnant client should not lie in the supine position because it puts her at risk for vena cava compression and subsequent supine hypotensive syndrome.
B) Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.
CORRECT
The lateral position supports placental perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the blood pressure 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.
C) Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level.
INCORRECT
While sitting is an appropriate position, the arm should be resting on a surface at heart level. In addition, Jennie is on bedrest with bathroom privileges, which does not include sitting up in a chair.
D) Have Jennie stand briefly and take the blood pressure on the right arm.
INCORRECT
A standing blood pressure does not provide the most valid reading. In addition, Jennie is on bedrest with bathroom privileges, which does not include standing at the bedside.
The nurse performs a nonstress test to evaluate fetal well-being.
7.
When performing a nonstress test (NST), the nurse will be assessing for which parameters?
A) Accelerations of the fetal heart rate in response to fetal movement.
CORRECT
The basis for the nonstress test is that the normal fetus with an intact CNS will respond to fetal movements by increasing its heart rate (episodic accelerations). A reactive test is one in which the fetus displays at least 2 accelerations of 15 beats per minute that last for 15 seconds in a 20-minute period in the presence of a normal baseline rate and moderate variability.
B) Late decelerations of the fetal heart rate in response to fetal movement.
INCORRECT
Late decelerations are a sign of uteroplacental insufficiency, and are assessed for in response to uterine contractions, not fetal movement.
C) Accelerations of the fetal heart rate in response to uterine contractions.
INCORRECT
Accelerations that occur with contractions (periodic accelerations) are usually linked to breech presentations, and are not the basis for the nonstress test.
D) Late decelerations of the fetal heart rate in response to uterine contractions.
INCORRECT
Late decelerations in response to uterine contractions are the basis for the contraction stress test.
HELLP Syndrome
At 0800, physical assessment and labs reveal the following: the client is still complaining of a headache but the epigastric pain has slightly decreased. While resting in a left lateral position, the vital signs are BP 146/94, P 75, R 18. Hyperreflexia continues with one beat of clonus. The baseline fetal heart rate is 140 with moderate variability and no decelerations. Since completion of a reactive nonstress test, no further accelerations have occurred.
Lab results include: hemoglobin - 13.1 g/dl, hematocrit - 40.5 g/dl, platelets - 120,000 mm3, aspartate aminotransferase (AST) - slightly elevated, alanine aminotransferase (ALT) - normal for pregnancy, 0 burr cells on slide, clotting studies normal for pregnancy.
The healthcare provider diagnoses Jennie with preeclampsia rather than HELLP syndrome, a variant of severe preeclampsia.
8.
If Jennie had HELLP syndrome, which lab results would the nurse expect her to exhibit?
A) Elevated hemoglobin and hematocrit (H&H) without burr cells, elevated liver enzymes, platelet count >150,000 mm3.
INCORRECT
Elevated H&H without burr cells and platelets >150,000 mm3 are not indicative of HELLP syndrome.
B) Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count <100,000 mm3.
CORRECT
All of these indicate HELLP syndrome. 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 <100,000 mm3.
C) Elevated hemoglobin and hematocrit (H&H) with burr cells, decreased liver enzymes, platelet count <100,000 mm3.
INCORRECT
An elevated H&H and decreased liver enzymes are not indicative of HELLP syndrome.
D) Decreased hemoglobin and hematocrit (H&H) without burr cells, decreased liver enzymes, platelet count >150,000 mm3.
INCORRECT
None of these results indicate HELLP syndrome.
Client Assignment
The day shift charge nurse is preparing to make client care assignments.
9.
Which client should be assigned to the most experienced RN?
A) A 15-year-old gravida 1, para 0, with mild preeclampsia.
INCORRECT
While this client is certainly high risk, her condition is not the most critical. She does, however, require diligent maternal/fetal monitoring and close observation because her condition can deteriorate rapidly.
B) A 35-year-old gravida 3, para 2, with HELLP syndrome.
CORRECT
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 to 12% of severely preeclamptic clients. It is commonly seen in older, Caucasian, multiparous clients. The symptoms of HELLP syndrome are somewhat different than those of preeclampsia. The client may complain of a general feeling of malaise over several days, have epigastric or upper abdominal pain, and may experience nausea and vomiting. The blood pressure may be only slightly elevated, or it may even be normal. In addition, proteinuria may be absent. A non-DIC coagulopathy is often associated with HELLP syndrome.
C) A 23-year-old gravida 2, para 0, with gestational diabetes.
INCORRECT
While this client is certainly high risk, her condition is not the most critical. Close monitoring of blood glucose levels, as well as diligent maternal/fetal monitoring is necessary, especially if insulin is needed for glucose control in the intrapartum period.
D) A 16-year-old gravida 1, para 0, with preterm labor.
INCORRECT
While this client is certainly high risk, her condition is not the most critical. She does, however, require diligent maternal/fetal monitoring, especially if she progresses to the point where she requires the use of tocolytic medications.
Plan of Care: Magnesium Sulfate Administration
Prior to initiating the healthcare provider's prescription, the nurse must first obtain consent for vaginal and cesarean birth, analgesia and anesthesia, and blood transfusion. The nurse is aware that pregnant adolescents are considered emancipated minors. Therefore, Jennie can sign the consent forms herself.
The healthcare provider prescribes this plan of care for Jennie:
Obtain permits for vaginal birth, cesarean birth, analgesia/anesthesia, and blood transfusion.
Start on magnesium sulfate (4 gm bolus over 20 min, then 1 gm/hr per pump) per unit protocol.
Follow standing magnesium sulfate protocol (may vary by hospital):
Primary IV: Lactated Ringer's solution
Total fluid volume: 150 ml/hour
Insert Foley catheter with urimeter attachment for hourly I&O
Bedrest
Vital signs & DTRs hourly after stabilized on magnesium sulfate
Continuous uterine and fetal monitoring
Calcium gluconate at bedside
Begin oxytocin (Pitocin) induction per protocol.
10.
What is the primary action of magnesium sulfate when given in preeclampsia?
A) An antihypertensive.
INCORRECT
While there is some relaxation of blood vessel walls resulting in a slight decrease in the BP, magnesium sulfate is not an antihypertensive. If a pregnant client needs an antihypertensive, the drugs of choice are Apresoline or Labetalol.
B) A diuretic.
INCORRECT
Magnesium sulfate is not a diuretic.
C) A CNS depressant.
CORRECT
Magnesium sulfate depresses the CNS by interfering with the neuromuscular junction. It is given to prevent or control eclamptic seizures.
D) A calcium channel blocker.
INCORRECT
Magnesium sulfate is not a calcium channel blocker.
11.
Since Jennie is receiving magnesium sulfate and oxytocin, the nurse should make what adjustments in the oxytocin (Pitocin)?
A) No adjustment to the oxytocin induction.
INCORRECT
Magnesium sulfate will have an effect on the induction.
B) Oxytocin is contraindicated and should not be given.
INCORRECT
Magnesium sulfate is not contraindicated when oxytocin is given.
C) Less oxytocin is needed to establish labor.
INCORRECT
Magnesium sulfate does not potentiate oxytocin, so this statement is incorrect.
D) More oxytocin is needed to establish labor.
CORRECT
It is highly likely that more oxytocin will be needed to establish labor due to the smooth muscle (uterine) relaxation caused by the magnesium sulfate.
12.
Which assessment finding would indicate to the nurse that a client is experiencing magnesium sulfate toxicity?
A) Complaints of chills and nervousness.
INCORRECT
Chills and nervousness are not side effects of magnesium sulfate toxicity.
B) Respiratory rate is <12 and absent DTRs.
CORRECT
Both indicate toxicity as does urine output of <30 ml/hr.
C) Mild sedation and sleeping between contractions.
INCORRECT
Mild sedation is an expected side effect of magnesium sulfate.
D) Urine output >50 ml per hour.
INCORRECT
A urine output >50 ml per hour is not indicative of magnesium sulfate toxicity.
A Legal Issue
The nurse asks Jennie if the healthcare provider has discussed labor and delivery processes, potential complications, and the management of those complications with her, and if she understands them. Jennie replies, "I think so," then asks for a pen.
13.
Which action should the nurse take?
A) Witness the signatures after Jennie and her sister have signed the consent form.
INCORRECT
It is not clear by Jennie's answer that she understands the provider's plan of care. In addition, Jennie is an emancipated minor in her state so her sister does not have to co-sign.
B) Call the healthcare provider to explain all procedures again before asking Jennie to sign.
INCORRECT
This may need to be done eventually, but it is not the most appropriate choice at this point.
C) Explain all the procedures and risks, and then ask Jennie to sign.
INCORRECT
It is never the role of the nurse to assume responsibility for the explanation of medical/surgical procedures and risks in the consent process.
D) Ask Jennie to explain what she understands about the procedures.
CORRECT
It is the responsibility of the nurse to ascertain what the client understands about the procedures, and the potential risks associated with those procedures. The nurse may also answer any questions Jennie has. If the nurse believes that Jennie is reasonably informed, the nurse may ask for her signature, after which the signature may then be witnessed and the consent forms placed in the chart. If the nurse believes that Jennie does not fully understand, a call to the healthcare provider is warranted.
Jennie's sister offers to sign the consent forms for her because Jennie is so young and just isn't feeling well right now.
14.
Which response by the nurse is correct?
A) "That would be fine. Please read over the forms before you sign."
INCORRECT
The sister is not the proper person to sign Jennie's forms.
B) "If Jennie does not feel like signing, we will have her partner do it."
INCORRECT
Unless the partner is Jennie's legal next of kin (husband), he cannot sign the consent forms. If they were married, even though he is only 17, this would be appropriate in most, if not all, states because he would be an emancipated minor. The nurse is responsible for knowing who can and cannot consent, based on individual state law.
C) "Do you have a number for your parents? I will call them for permission."
INCORRECT
Jennie's parents are not the proper people to sign her consent forms.
D) "Jennie should sign the consent forms herself since she is the one receiving the care."
CORRECT
Jennie is the person who should sign the consent forms. The nurse has already determined that in their state, pregnant minors are considered emancipated. By validating Jennie's role in informed consent and the decision-making process, client empowerment is enhanced. With Jennie's permission, her family may also be involved in the discussion and decision-making process.
Evaluation
The 0900 assessment reveals: Jennie reports that her headache has decreased slightly, but the epigastric pain has increased. Complaints of scotoma began about 5 minutes ago. Reflexes are 4+ biceps and patellar and 3+ triceps with 3 beats of ankle clonus. Vital signs are: T 99° F, P 80, R 19, BP 144/96.
The most recent blood magnesium level is 2 gm/dl. Intake since admission (@0600) is 150 ml and output is 300 ml. The healthcare provider increases the magnesium sulfate prescription to 2 gm/hr.
Fetal monitor tracing reveals a baseline fetal heart rate in the 120s, minimal variability, no accelerations, and no decelerations. Uterine contractions are occurring every 4 to 5 minutes and they are moderate quality upon palpation. Cervical exam indicates the cervix is now 3 cm dilated and 80% effaced, with the presenting part (cephalic) at -1 station. Jennie reports mild discomfort with contractions but does not want anything for pain at this time.
Jennie's partner and sister are at the bedside helping her use relaxation breathing through each contraction. Jennie is in the right lateral position with the head of the bed slightly elevated.
Jennie asks why the magnesium sulfate was increased.
15.
What explanation should the nurse provide?
A) The magnesium is being excreted through the kidneys.
CORRECT
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 to 8 mg/dl) because it is being excreted from the body.
B) The anxiety caused by labor contractions is affecting the drug's efficacy.
INCORRECT
Anxiety can increase BP, but it does not affect the magnesium level.
C) The healthcare provider should have also ordered an antihypertensive.
INCORRECT
This is not a nursing judgment. Antihypertensive drugs do not potentiate the effects of magnesium sulfate. However, if the BP continues to rise, the nurse should report it to the healthcare provider who may prescribe an antihypertensive.
D) The Pitocin is having an adverse interaction with the magnesium.
INCORRECT
Pitocin does not affect magnesium levels.
When the nurse evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate with minimal variability.
16.
What is the best explanation for this change?
A) Cord compression is occurring due to oxytocin crossing the placenta.
INCORRECT
Although the increased contractions can cause cord compression in some fetuses, this is not a cause of decreased variability. Pitocin itself does not cause the decreased variability.
B) The fetus' head is descending further into the pelvis.
INCORRECT
The head coming into the pelvis (at -1 station) would cause early decelerations, which are normal, but it is not related to a decrease in variability.
C) The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated.
CORRECT
Because magnesium sulfate crosses the placenta, the baby will have a magnesium level equal to the mother. Although sources differ on the effect that magnesium levels have on long term variability, many sources do attribute a decrease in long-term variability to magnesium sulfate. Other sources believe that magnesium sulfate does not affect fetal heart rate variability in a healthy term fetus whose weight is normal for gestational age. However, this fetus is preterm (36-weeks), and all fetuses of mothers with hypertensive diseases during pregnancy are at risk for intrauterine growth restriction (IUGR) related to poor placental perfusion.
D) The mother's hypertension has caused an acute stress incident in the fetus.
INCORRECT
While a mother's hypertension may decrease placental perfusion, Jennie came in with an elevated BP. Because the baby had moderate variability upon admission, it is unlikely the change in BP is the best explanation for the change.
A Complication Occurs
At 0930 Jennie's sister rings the call bell and yells, "Come quickly, Jennie is shaking all over." The nurse determines that Jennie is experiencing an eclamptic seizure.
17.
Which nursing intervention takes priority?
A) Observe fetal monitor for non-reassuring patterns of FHR.
INCORRECT
This should be done, but another action should take priority.
B) Turn Jennie onto her side and place a pillow behind her to stabilize position.
CORRECT
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 patent airway can be maintained, the aspiration of vomitus minimized, and supine hypotension prevented.
C) Make a note of the time and sequence of the eclampsia seizure.
INCORRECT
This should be done, but another action takes priority.
D) Suction the mouth, or oropharynx, and then apply oxygen at 10 liters per minute by facemask.
INCORRECT
Suctioning should be done only after the seizure ceases. The oxygen should be applied.
After the seizure ends, the nurse assesses the status of membranes, which may have ruptured during the seizure, as well as the fetal heart rate and the contraction status.
The nurse observes the following pattern on the external fetal monitor: Contractions occur every 3 minutes and last 60 seconds. The baseline fetal heart rate is 130 beats per minute, and there is minimal variability. At the peak of each contraction, the fetal heart rate gradually decreases to 117 beats per minute, then returns to the baseline 15 seconds after the contraction ends. At 1030 the nurse notes Jennie's output is 30ml/hr and spontaneous rupture of membrances (SROM) has occurred with clear amniotic fluid.
18.
The nurse recognizes what type of periodic fetal heart rate change that is occurring?
A) Variable decelerations.
INCORRECT
Variable decelerations are frequently the result of cord compression. Variable decelerations may occur anytime -- before, during, or after contractions. These decelerations display an abrupt onset and often an abrupt recovery. They may be U, V, or W shaped. Some are accompanied by brief accelerations before and/or after the deceleration (a compensatory response to the umbilical cord compression).
B) Early decelerations.
INCORRECT
Early decelerations are the result of fetal head compression. While the decrease in rate and increase to baseline is gradual, it mirrors the contractions, starting as the contraction begins and finishing as the contraction ends. These are benign decelerations and are considered reassuring.
C) Transient bradycardia.
INCORRECT
Bradycardia in the fetus is defined as a baseline of less than 110 beats per minute for a duration of 10 minutes or longer.
D) Late decelerations.
CORRECT
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 acidemia. In Jennie's case, the late decelerations stem from the eclamptic seizure, during which the oxygen supply to the mother and fetus was compromised.
Jennie is lying on her left side. Oxygen is being administered via mask at 10 liters per minute. Both of these actions incorporate principles of intrauterine resuscitation. Intrauterine resuscitation is directed toward improving uterine blood flow and increasing maternal oxygenation and cardiac output.
19.
What should the nurse do next to ensure intrauterine resuscitation?
A) Implement a prescribed fluid bolus to improve maternal blood volume.
CORRECT
A bolus of non-dextrose IV fluid (normal saline or Ringer's lactated) will increase the maternal fluid volume, thereby improving blood flow and oxygenation to the fetus. Jennie already has a decrease in volume, secondary to her preeclampsia. For Jennie, the bolus will be carefully controlled, due to her decreased kidney function.
B) Increase the oxytocin infusion rate to hasten the birth.
INCORRECT
This fetus is already displaying a nonreassuring fetal heart rate pattern. Increasing the oxytocin will increase uterine contractions that could further stress the fetus.
C) Elevate the head of the bed 90 degrees to improve cardiac output.
INCORRECT
The right or left lateral position most effectively promotes maternal cardiac output, thus enhancing blood flow to the fetus.
D) Decrease the magnesium sulfate rate to improve uterine contractility.
INCORRECT
While it is true that magnesium sulfate can decrease uterine contractility, it should not be decreased. Jennie is still at risk for seizure, and her magnesium sulfate will be increased or decreased based on magnesium levels and clinical response.
Prevention and Treatment of Medication Complications
No further seizures occur, and at 1100 the nursing assessment reveals that Jennie is groggy but responsive with hand grasp weak bilaterally. Her DTRs are 1+ biceps, triceps, and patellar with no ankle clonus. Vital signs: BP 138/88, P 82, R 14.
The most recent magnesium level is 8 gm/dl. The hourly intake is 175 ml, and the output is now 30 ml.
The baseline fetal heart rate via external monitor is baseline 130 with minimal variability. There are no accelerations, and the decelerations have ceased. Spontaneous rupture of the amniotic membranes (SROM) occurred with the seizure, and the fluid was clear. Contractions are occurring every 3 minutes and lasting 60 seconds. The contractions are strong to palpation. Vaginal exam by the healthcare provider reveals that the cervix is dilated 7 cm and is 100% effaced and that the fetal head is at 0 station.
The healthcare provider makes the decision to continue labor rather than perform a cesarean section because both mother and baby are stabilizing, and the cervix is changing. Jennie is crying with each contraction and requests something for pain. After consultation with the anesthesia provider, the healthcare provider prescribes an epidural using a local anesthetic agent as opposed to an opioid analgesic.
20.
What medication should the nurse have readily available as an antidote for magnesium sulfate?
A) Naloxone (Narcan).
INCORRECT
Narcan is an opioid antagonist that is used to reverse CNS depressant effects, especially respiratory depression.
B) Calcium gluconate.
CORRECT
Calcium gluconate is the antidote for magnesium sulfate. The usual dose is 10 milliliters of a 10% solution (1 gram). It is given slow IV push over at least 3 minutes. The client should be monitored carefully for cardiac reactions such as dysrhythmias, bradycardia, and ventricular fibrillation.
C) Propranolol (Inderal).
INCORRECT
Inderal is the antidote for beta-2 adrenergic agonists, such as ritodrine (Yutopar) and terbutaline (Brethine).
D) Protamine sulfate.
INCORRECT
Protamine sulfate is the antidote for heparin.
21.
Which complication is Jennie most at risk for following the epidural with a local anesthestic, such as bupivacaine or ropivacaine?
A) Respiratory depression.
INCORRECT
Respiratory depression is more likely to occur when opioid analgesics such as fentanyl, sufentanil, or preservative-free morphine are used. The client receiving these medications should be assessed for respiratory depression hourly for at least 24 hours after the epidural is discontinued.
B) Elevated temperature.
INCORRECT
There is some evidence that clients who receive an epidural, especially one lasting more than 12 hours, may have an elevated temperature. However, Jennie is at greater risk for another complication.
C) Hypotension.
CORRECT
Hypotension occurs as a result of the sympathetic blockade. It is a common occurrence after an epidural if the mother is not adequately pre-hydrated, or already has an impaired fluid volume, as Jennie does due to her preeclampsia. It can be prevented by adequate pre-load. For clients at risk for fluid overload, the use of central monitoring is indicated. The use of the side-lying position will also aid in preventing hypotension due to vena caval compression that occurs in the supine position. Ephedrine is the vasopressor of choice should severe hypotension occur. However, it is given only after fluid volume replacement, oxygen administration, and lateral position are implemented, yet unsuccessful.
D) Spinal headache.
INCORRECT
If the dura was accidentally punctured during epidural insertion, the client could develop a postdural puncture headache (spinal headache). However, the client is at greater risk for another complication.
Client Teaching: Pushing Technique
At 1130 Jennie complains of rectal pressure and an urge to push. Her headache is worsening, but she reports no scotoma and no epigastric pain. Her vital signs are: T 98.4° F, P 70, R 16, BP 130/83. DTRs are 1+ biceps and triceps; unable to elicit patellar, no clonus.
Intake for the last hour is 150 ml, and output is 30 ml.
The baseline fetal heart rate is 120 with minimal variability, positive for accelerations and mild variable decelerations. Strong contractions lasting 70 seconds are occurring every 2 to 3 minutes. Jennie's cervix is now 10 cm dilated, and the fetal head is at +3 station. The nurse informs the healthcare provider. Because Jennie is completely dilated and has the urge to push, the nurse reviews the proper pushing technique with Jennie and her partner.
22.
What should the nurse tell Jennie?
A) 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.
CORRECT
This method of pushing utilizes both instinctive, spontaneous pushing and open-glottis pushing. It is physiologically correct in that it utilizes Ferguson's reflex (the urge to bear down), at which time more oxytocin is released from the exterior pituitary to strengthen bearing-down contractions. Exhalation while pushing, limiting the amount of time breath is held, and taking deep breaths in between pushing efforts, help maintain adequate oxygenation to the mother and fetus. This technique results in approximately 5 pushes during each contraction and is less likely to overtire the mother. This is in opposition to closed-glottis (prolonged breath-holding while pushing) technique which may trigger the Valsalva maneuver. If that occurs, the increased intrathoracic and cardiovascular pressures reduce cardiac output and diminish perfusion of oxygen across the placenta, putting the fetus at risk for hypoxia.
B) When the contraction begins on the fetal monitor, take a deep breath and hold it while bearing down for 10 seconds. Then take a quick breath and repeat the pushing pattern until the contraction ends on the monitor.
INCORRECT
Although this technique is commonly seen in practice, it has the potential to harm the fetus.
C) When the nurse palpates a contraction's beginning, take three shallow breaths and hold the breath for as long as possible while bearing down without allowing air to escape.
INCORRECT
This practice is not physiologically appropriate and has the potential to harm the fetus.
D) When the urge to push is felt, more of the epidural analgesic should be injected and the nurse will tell the client when and how to push each time there is a contraction.
INCORRECT
An epidural often reduces or blocks the urge to bear down. Analgesic doses are often adjusted to the lowest level possible to keep the client comfortable while maintaining the urge to push.
1230: A Baby is Born
Jennie gives birth vaginally to a baby girl. The Apgar score is 2 at 1 minute, 6 at 5 minutes, and 7 at 10 minutes. After Jennie and her partner hold the baby for a few minutes, the baby is taken to the neonatal intensive care unit (NICU) for observation. The placenta is delivered spontaneously, and Jennie remains in the labor/delivery/recovery room.
23.
The NICU nurse anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate?
A) Hyperreflexia and increased respirations.
INCORRECT
This is not the combinations of complications expected with elevated magnesium levels (hypermagnesemia).
B) Hyporeflexia and irregular respirations.
INCORRECT
This is not the combination of complications expected with hypermagnesemia.
C) Hyporeflexia and decreased respirations.
CORRECT
Because magnesium sulfate crosses the placenta, the newborn can develop toxic levels of magnesium. Neonatal hypermagnesemia manifests as hypotonia, and a marked decrease in respiratory rate. This is not to be confused with irregular respirations, which are common in all infants. Hypermagnesemia may be treated with calcium and exchange transfusion with citrated blood, and/or assisted mechanical ventilation until serum levels are normal. As with the mother, magnesium is cleared through the kidneys.
D) Hyperreflexia and irregular respirations.
INCORRECT
This is not the combination of complications expected with elevated magnesium levels (hypermagnesemia).
Post-birth Care
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.
24.
Which room and nursing staff assignments should be made for Jennie?
A) Move Jennie to the mother/baby unit and assign an RN with two other mother/baby couplets to care for her.
INCORRECT
Nurse/mother/baby couplet ratios are too high for the hourly assessment needed when a client remains on magnesium sulfate.
B) Keep Jennie in recovery with an RN who is also caring for 4 other recovering mothers.
INCORRECT
The care ratio is too high. In addition, a client with preeclampsia has an irritated CNS, so a room with other patients (and usually family members) is inappropriate due to the risk of overstimulation.
C) Move Jennie to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her.
CORRECT
A quiet room with one-to-one care is the most appropriate assignment. Clients with preeclampsia, even if they have not seized prior to birth, remain at risk for seizures. Magnesium is continued for at least 12 to 24 hours, based on the client's condition. Close assessment, including frequent vital sign monitoring, reflex checks, and I&O measurement is necessary. In addition, since magnesium relaxes smooth muscle, Jennie is at greater risk for postpartum hemorrhage.
D) Move Jennie to the Intensive Care unit (ICU) where an RN with one other client can care for her.
INCORRECT
While ICU is often needed for clients with preeclampsia, particularly those who seize and/or require hemodynamic monitoring, Jennie is stable at present and does not require a transfer to the ICU.
Jennie's partner asks if some friends can come and watch television with him now that the baby has been born."
25.
Which response by the nurse is most appropriate?
A) "Absolutely not! Do you want to make her condition worse?"
INCORRECT
This response is both condescending and judgmental.
B) "You are a parent now. You have lots to learn while you're here."
INCORRECT
This response is both condescending and judgmental. While it is true that this young father may need to learn how to properly care for his partner and new baby, this is not the way to open communication about his educational needs.
C) "Your partner is still at risk for complications, so visitors are limited to family members, and only for a short period of time."
CORRECT
This answer gives Jennie’s partner the facts about her condition (still at risk for complications). While peer contact is a part of the adolescent’s developmental process, client safety comes first in this case. By treating the partner as an adult and explaining why his request cannot be met, it can enhance his self-worth and may help him define his role as a new father.
D) "Sure. I know that you both miss your friends. Tell them to come, but remind them that Jennie just had a baby."
INCORRECT
This could compromise Jennie's safety. She is just a few hours postpartum and less than 5 hours postseizure. As her condition stabilizes, Jennie will be able to assume normal postpartum activities.
The nurse is aware that continued magnesium sulfate puts Jennie at risk for postpartum hemorrhage even though Pitocin is infusing.
26.
The nurse recognizes which medication is safest for Jennie if a second drug is needed to treat postpartum hemorrhage?
A) Carboprost tromethamine (Hemabate).
CORRECT
This medication, a derivative of prostaglandin F2 alpha may be administered intramuscularly, intramyometrially at cesarean birth, or intraabdominally after vaginal birth. When given intramuscularly in the postpartum period, the usual dose is 25 mg every 15 to 90 minutes for up to 8 doses. This drug may be used with the hypertensive client.
B) Methylergonovine (Methergine).
INCORRECT
An ergot derivative, this medication is contraindicated for the client with preeclampsia because it increases the blood pressure.
C) Ergonovine (Ergotrate).
INCORRECT
An ergot derivative, this medication is contraindicated for the client with preeclampsia because it increases the blood pressure.
D) Leonurus (Motherwort).
INCORRECT
While this herbal preparation is recognized as a remedy for postpartum hemorrhage, it is contraindicated in preeclampsia because it is vasoconstrictive. In addition, published evidence of safety and efficacy is lacking.
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