Preeclampsia
The nurse is assessing a pregnant woman with gestational hypertension. Which of the following would lead the nurse to suspect that the patient has developed severe preeclampsia?
Proteinuria
If the patient with preeclampsia progresses from preeclampsia to eclampsia, the nurse should take which action first?
Clear and maintain an open airway.
The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to
Assess fetal heart rate and maternal vital signs.
. A 28 year old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension. What risk factor below found in the patient's health history places her at risk for abruptio placentae?*
B. preeclampisa
A pregnant woman hospitalized with severe preeclampsia is being treated with hydralazine to control blood pressure. Which of the following would the lead the nurse to suspect that the patient is having an adverse effect associated with this drug?
Tachycardia
The nurse is reviewing the laboratory test results of a pregnant patient diagnosed with preeclampsia. Which one of the following findings would alert the nurse to the development of HELLP syndrome?
Elevated liver enzymes (AST and ALT)
The development of seizures in preeclamptic women
Eclampsia
Occurs when the placenta abnormally implants in the lower segment of the uterus near o over the cervical os instead of attaching to the fundus.
Placenta previa.
A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can present with abruptio placentae? Select all that apply:
A. Decrease in fundal height
B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. Tender uterus
B. Hard abdomen
C. Fetal distress
E. Tender uterus
A patient taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take?
Administer Calcium gluconate
The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse includes interventions focusing on which of the following because of the woman's increased risk?
Preeclampsia
The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom's body, which injures organs.
Endothelial cells
when the cervical os is completely covered by the placental attachment
Complete or total Placental Previa
Acceleration of fetal lung maturity to reduce the incidence and severity of respiratory distress syndrome.
Betamethasone
Decreased perfusion to organs.
Systemic vasospasms
Vascular damage
Coag abnormalities
Maternal complications of preeclampsia
A patient with preeclampsia is complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
Worsening disease and impending convulsion
Onset of painless, bright red vaginal bleeding after 20th week of pregnancy, usually before 30 weeks' gestation
Vaginal bleeding before labor onset, typically episodic and stopping spontaneously
Possibly no symptoms
Subjective assessment of placenta previa
Nursing interventions for this condition includes measuring the fundal height
A patient diagnosed with preeclampsia and is receiving magnesium sulfate. Which finding would the nurse interpret as indicating a therapeutic level of medication?
Deep tendons reflexes 2+
The nurse is creating a plan of care for a 38 weeks gestation pregnant woman with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this patient?
1.)Keep the room semi-dark.
2.)Initiate seizure precautions.
3.)Pad the side rails of the bed.
4.)Avoid environmental stimulation
Sustained systolic blood pressure (BP) greater than 160 mm Hg or diastolic greater than 110 mm Hg
Tachycardia
Tachypnea
Rales
Mental status changes
Clonus
Hyperreflexia
Oliguria or anuria
Localizing neurologic deficits
Generalized edema
Small fundal height for estimated gestational age
Visual disturbances
Signs of Eclampsia
previous placenta previa
-uterine scarring (previous cesarean birth, curettage, endometritis)
-maternal age greater than 35 to 40 years
-multifetal gestation
-multiple gestations or closely spaced pregnancies
-smoking
Risk Factors for placenta previa
A 20-year-old pregnant patient at 40 weeks gestation is diagnosed of preeclampsia with sever features; she is in labor and being treated with magnesium sulfate for seizure prophylaxis. Mention at least three priority assessments with this medication?
1.) Check the respiratory rate.
3.) Check deep tendon reflexes.
4.) Monitor the urine output (30-50cc/hr).