Pre-eclampsia/Eclampsia/PIH
List two priority nursing interventions for a patient with preeclampsia without severe features.
Frequent BP monitoring, assess DTRs and urine output, promote bed rest on the left side, and educate on warning signs.
Explain why visual disturbances occur in severe preeclampsia.
Cerebral edema and vasospasm cause blurred vision, photophobia.
Describe pneumothorax
Air enters the pleural space, causing partial or complete collapse of the lung.
Name the three chambers in a traditional chest drainage system.
Collection chamber, water seal chamber, and suction control chamber
What is the purpose of mechanical ventilation in ARDS?
Supports oxygenation and CO₂ removal when lungs fail to exchange gases.
This condition usually develops after this point in pregnancy (in weeks).
After 20 weeks gestation.
Which laboratory value indicates liver involvement in preeclampsia with severe features?
Elevated AST/ALT (liver enzymes).
What physical assessment finding is commonly heard on the affected side?
Absent or diminished breath sounds on the affected side.
What is the function of the collection chamber?
Collects drainage (blood, fluid, or air) from the pleural cavity.
Define PEEP and explain why it’s used.
Positive End-Expiratory Pressure (PEEP) keeps alveoli open at end-expiration, improving oxygenation.
True or False: The presence of edema alone is sufficient to diagnose preeclampsia.
False – edema is nonspecific and not diagnostic.
Describe the rationale for administering magnesium sulfate to a patient with preeclampsia with severe features.
To prevent seizure activity by depressing CNS irritability.
What makes a tension pneumothorax different from other types?
Air enters pleural space but cannot escape — a one-way valve effect.
The nurse is assessing a client with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?
Notify the health care provider.
Describe the primary pathophysiologic change that occurs in the alveoli during ARDS.
Alveolar-capillary membrane damage → protein/fluid leak → hyaline membrane formation → ↓ gas exchange.
Systolic ≥ ___ mmHg or diastolic ≥ ___ mmHg qualifies as “severe” hypertension.
≥160 systolic or ≥110 diastolic mmHg.
What is the definitive treatment for eclampsia?
Delivery of the fetus (after stabilizing the mother).
Why is a tension pneumothorax life-threatening?
Pressure compresses heart and great vessels → obstructive shock.
What should the nurse do if the chest tube becomes disconnected from the drainage system?
Immerse the tube end in sterile water to maintain seal; notify provider.
The nurse is caring for a client who is intubated and receiving mechanical ventilation. The nurse responds to an alarm on the volume-cycled ventilator and finds the high-pressure alarm is ringing. Which problem should the nurse expect to find when assessing the client and equipment?
There is a kink in the ventilator tubing.
Name two target organs affected in preeclampsia with severe features.
Brain, liver, kidneys (also can include lungs or hematologic system).
List at least three warning signs that precede an eclamptic seizure.
Headache, blurred vision, epigastric pain, hyperreflexia, restlessness, or severe hypertension.
What is the immediate emergency treatment for a tension pneumothorax?
Needle decompression in 2nd intercostal space, midclavicular line, followed by chest tube insertion.
True or False: The nurse should milk or strip the tubing to improve drainage.
False: Do not milk/strip unless ordered; it can create dangerous negative pressure.
A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?
prevents the aspiration of oral fluids