Central Philippine University

College of Nursing

N418 Competency Appraisal 1

CASE PRESENTATION ON
PREGNANCY
INDUCED
HYPERTENSION

PASSED BY
MARY ROMELYNE PEDOCHINO

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 TABLE OF CONTENTS
I. PRE-TEST ---------------------------------------------------- 3
II. CASE SCENARIO ----------------------------------------- 9
III. OBJECTIVES ----------------------------------------------- 9
IV. MINI-LECTURE --------------------------------------------- 10
V. PATHOPHYSIOLOGY ------------------------------------ 12
VI. LEVELS OF CARE ---------------------------------------- 13
VII. NURSING CARE PLAN ---------------------------------- 14
VIII. ELEVEN KEY AREAS OF RESPONSIBILITIES – 15
IX. IMPLICATIONS / INSIGHTS --------------------------- 20
X. BIBILIOGRAPHY ------------------------------------------ 21
XI. POST – TEST ----------------------------------------------- 22

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 I. Pretest
1. The nurse concludes that a client is at risk for pregnancy-induced hypertension (PIH) when
the vital signs taken during pregnancy show that the blood pressure increases from:

a. 122/80 to 138/86.
b. 100/60 to 130/76.
c. 90/56 to 110/70.
d. 134/80 to 140/88.

A:
b. 100/60 - 130/76
Rationale:
An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for
PIH. The other examples do not meet these criteria.

2.The nurse is caring for a woman who has been admitted with early pregnancy-induced
hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to:
a. Check the blood pressure and fetal heart tones.
b. Maintain a patent airway.
c. Administer oxygen.
d. Prepare to administer magnesium sulfate.
A:
b. patent airway
Rationale:
The woman experiencing eclampsia is at great risk for seizures, and the highest priority of care
is a patent airway. Checking blood pressure, fetal heart tones, and administering magnesium
sulfate and oxygen are all components of care but are of lower priority than maintaining a patent
airway.

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3.The nurse is evaluating a woman at 48 hours postpartum who experienced pregnancy-
induced hypertension (PIH). Which of the following would lead the nurse to conclude that the
PIH has not resolved?

a. Blood pressure is returned to baseline.

b. Client complains of perineal pain.
c. Urine output is increasing.
d. Client complains of headache and blurred vision.

A:
d. ha and blurred vision

Rationale :

Headache and blurred vision are symptoms of the disorder, indicating that the PIH has not
resolved. Baseline blood pressure and increasing urine output are signs that PIH is resolving.
Perineal pain is unrelated to PIH.

4. The nurse is performing a routine prenatal assessment of a client at 23 weeks' gestation.

Which of the following would indicate to the nurse that the client may be experiencing
pregnancy-induced hypertension (PIH)?

a. A baseline blood pressure of 122/80.

b. Proteinuria.
c. Complaints of low back pain.
d. Glucose in the urine.
A:
b. proteinuria
Rationale:
PIH begins to occur at 20 weeks' gestation, and proteinuria is one sign that the client is
experiencing PIH. A baseline pressure is not a determining factor for PIH. Glucose in the urine

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indicates possible gestational diabetes, which puts the client at risk for PIH, but is not diagnostic
for PIH. Back pain is unrelated to PIH.

5.The nurse is caring for a client with severe preeclampsia who is showing signs of bleeding
and oozing from intravenous sites and who is bruising under the skin. The nurse suspects which
of the following?

a. Transient hypertension.
b. Eclampsia.
c. Hemolysis, elevated liver enzymes, low platelet count syndrome (HELLP).
d. Chronic hypertensive disease.
A:
c. HELLP
Rationale :
Pregnant women with severe preeclampsia may develop HELLP syndrome, which has a very
poor prognosis. HELLP presents with nausea, vomiting, flulike symptoms, and bleeding due to
liver involvement and platelet aggregation. Eclampsia presents with seizures, blurred vision, and
high blood pressure. Chronic and transient hypertension may lead to HELLP syndrome.

5.The nurse is caring for a pregnant woman who is admitted with preeclampsia. The nurse
plans care based on the nursing diagnosis of deficient fluid volume related to fluid shifts from
vasospasms. Which of the following nursing interventions is a priority for this client? (Select all
that apply.)

a. Place client in the left lateral recumbent position.

b. Monitor for increased urine output.
c. Weigh client weekly.
d. Assess blood pressure every 8 hours.
e. Assess deep tendon reflexes.
A:
a. left lateral recumbent position
e. deep tendon reflexes
Rationale :

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The left lateral position reduces pressure on the vena cava, thereby increasing venous return.
Hyperreflexia indicates central nervous involvement and is a sign of progression toward
eclampsia. Blood pressure is assessed every 1-4 hours. Urine output is decreased in
preeclampsia; the client is weighed daily for fluid status.

6.The nurse is instructing a client with mild pregnancy-induced hypertension (PIH) who is about
to be discharged home. The nurse teaches the mother to call the physician if which of the
following occurs?

a. Appetite increases.
b. Fetal movement slows or stops.
c. Back pain increases.
d. Edema decreases.
A:
b. movement slows or stops
Rationale:
The fetus is affected by PIH due to maternal vasospasms that decrease blood flow and nutrients
to the fetus, which may cause the baby to die if PIH worsens. Back pain and increased appetite
are not signs of worsening PIH. Edema increases as PIH progresses.

7. The nurse is caring for a client with severe pregnancy-induced hypertension who is in the
hospital on a magnesium sulfate drip. The nurse monitors the client for which of the following
signs of magnesium toxicity?

a. Slurring of speech.
b. Awkward movements.
c. Diminished reflexes.
d. Decreased appetite.
A:
c. diminished reflexes
Rationale :

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Diminished reflexes signify magnesium toxicity. Slurred speech, decreased appetite, and
awkward movements indicate a therapeutic magnesium level.

8. A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for
seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? select all

a. respirations fewer than 12/min

b. urinary output less than 30 mL/hr
c. hyperreflexic deep tendon reflexes
d. decreased LOC
e. flushing and sweating
A:
a. respers less than 12
b. urinary output less than 30
d. decreased LOC
Rationale :
c. absence of deep tendon reflexes
e. flushing and sweating are adverse effects not s/s of toxicity

9.A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following
medications should the nurse anticipate administering if magnesium sulfate toxicity is
suspected?

a. nifedipine
b. pyridoxine
c. ferrous sulfate
d. calcium gluconate
A:

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D. calcium gluconate
Rationale :
d. calcium gluconate is the antidote for magnesium sulfate

10. A client is diagnosed with gestational hypertension and is receiving magnesium sulfate.
Which finding would the nurse interpret as indicating a therapeutic level of medication?

A) Urinary output of 20 mL per hour

B) Respiratory rate of 10 breaths/minute
C) Deep tendons reflexes 2+
D) Difficulty in arousing
Ans: C
Rationale :
With magnesium sulfate, deep tendon reflexes of 2+ would be considered normal and therefore
a therapeutic level of the drug. Urinary output of less than 30 mL, a respiratory rate of less than
12 breaths/minute, and a diminished level of consciousness would indicate magnesium toxicity.

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II. CASE SCENARIO

Patient Ruby Jane Villongco a 21 years old, female currently residing at Brgy Poblacion 1 was admitted
to the hospital by stretcher with guard last November 25,2017, with a chief complaint of dizziness,
nausea, vomiting blurred vision and Edema on the hands. Patients’ blood pressure is 170/100 mmHg
and weighing 149lbs. Ruby Jane is G2P1, 33 4/7 weeks of gestation. Her husband is Hanbin Villongco, 25
years old, OFW in Qatar

Her last menstrual period was April 4, 2017 and her weight of 150 lbs. Her mother also has a history of
hypertension. She was hospitalized last 2013 because of appendicitis

III. OBJECTIVES

Objectives: To further explain and gain extensive knowledge regarding pregnancy induced hypertension.
This output is accomplished for a comprehensive analysis concerning pregnancy induced hypertension in
the following objectives:

On the completion of this Case Presentation, the listener will be able to:

 Differentiate signs and symptoms, effects on pregnancy and management of Pregnancy

Induced Hypertension
 Describe appropriate nursing interventions and use of medication for patients with
pregnancy induced hypertension.
 Discuss the Nursing Care Plan for PIH

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!V. Mini lecture

What is pregnancy-induced hypertension?

Pregnancy-induced hypertension — which may also be called pre-eclampsia, toxemia, or toxemia of

pregnancy — is a pregnancy complication characterized by high blood pressure, swelling due to fluid
retention, and protein in the urine.

Who is affected by pregnancy-induced hypertension (PIH)?

Pregnancy-induced hypertension (PIH) affects approximately 1 out of every 14 pregnant women.

Although PIH more commonly occurs during first pregnancies, it can also occur in subsequent
pregnancies. PIH is also more common in pregnant teens and in women over age 40. Many times, PIH
develops during the second half of pregnancy, usually after the 20th week, but it can also develop at the
time of delivery or right after delivery.

What is the danger of pregnancy-induced hypertension (PIH)?

PIH can prevent the placenta from receiving enough blood, which can cause low birth weight in your
baby. Although these complications are rare, PIH may cause the following:

Placental abruption, a complication that occurs when the placenta pulls away from the wall of the
uterus, causing maternal bleeding and fetal distress.

Seizures in the mother.

Temporary kidney failure.

Liver problems.

Blood clotting problems.

Early delivery of premature baby.

What are the symptoms of pregnancy-induced hypertension (PIH)?

Rapid or sudden weight gain, high blood pressure, protein in the urine, and swelling (in the hands, feet,
and face) are all signs of PIH. Some swelling is normal during pregnancy. However, if the swelling doesn't

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go away and is accompanied by some of the above symptoms, be sure to see your doctor right away.
Other symptoms of PIH include abdominal pain, severe headaches, a change in reflexes, spots before
your eyes, reduced output of urine or no urine, blood in the urine, dizziness, or excessive vomiting and
nausea.

How is pregnancy-induced hypertension (PIH) diagnosed?

During routine prenatal tests, your weight gain, blood pressure and urine protein are monitored. If you
have symptoms of PIH, as listed above, additional blood tests may be ordered, which would show
abnormal results if PIH is present.

If PIH is suspected, a non-stress test may be performed to monitor the baby. During the non-stress test,
an ultrasound transducer records the baby's heart rate, and a pressure transducer (called the toco
transducer) records uterine activity. Each time you feel the baby move, you make a mark on a graph
paper that displays the fetal heart rate and uterine activity.

Usually the fetal heart rate increases when the fetus moves, just as your heart beats faster when you
exercise. Certain changes in the fetal heart rate are considered a sign of good health. Sometimes an
ultrasound provides more information about the baby.

How is pregnancy-induced hypertension (PIH) treated?

If PIH is mild, it can be treated at home. If you have been diagnosed with PIH and your doctor
recommends home treatment, you will need to maintain a quiet, restful environment with limited
activity or bed rest on your left side.

It is important that you follow the diet and fluid intake guidelines from your health care provider and
maintain your scheduled appointments. Your perception of fetal movement every three hours is also
important. Any changes need to be reported to your health care provider immediately.

If PIH becomes worse, you will need to be admitted to the hospital where you can be closely monitored.
Your health care provider will work with you to maintain the health of you and your baby. In severe
cases, the baby may have to be delivered. High blood pressure is treated with medication, and
magnesium is given through an IV to prevent seizures.

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V. Pathophysiology

Pregnant women with blood pressure higher than 140/90

Before 20 wks of gestation After 20 wks of gestation

No or stable proteinuria New or increased Proteinuria No proteinuria

Proteinuria, developing
Chronic Hypertension Increased BP. Preeclampsia
Gestational HPN

Preeclampsia imposed
On chronic hypertension

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VI. Levels of care

Promotive

· Adequate rest with good ventilation

· Proper diet advised by the doctor

· Drink at least 8 glasses of water a day.

Preventive

· Early identification of women at risk for gestational hypertension may help prevent some
complications of the disease.

· Increased frequency of prenatal checkup.

· Elevate feet several times during the day.

· Avoid drinking alcohol

Curative

Drug treatment options are limited, as many antihypertensives may negatively affect the fetus.
Methyldopa, hydralazine, and labetalol are most commonly used for severe pregnancy
hypertension.[citation needed]

The fetus is at increased risk for a variety of life-threatening conditions, including pulmonary hypoplasia
(immature lungs). If the dangerous complications appear after the fetus has reached a point of viability,
even though still immature, then an early delivery may be warranted to save the lives of both mother
and baby. An appropriate plan for labor and delivery includes selection of a hospital with provisions for
advanced life support of newborn babies.

Rehabilitative

· Visit physical therapist for proper exercise during pregnancy.

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VII. NURSING CARE PLAN

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ELEVEN KEY AREAS OF RESPONSIBILITIES

Patient Care Competencies

Communicating

Active Listening- Being attentive to what the patient is saying, verbally and non-verbally. Sit facing the
patient, open posture, lean forward, eye contact and relax. Avoid interrupting the client while talking
and have full opportunity to speak freely and to ventilate his/her feelings.

Acknowledging the patient’s feelings- This helps the patient to know that his/her feelings are
understood and accepted and encouraged him to verbalize his feelings even more.

Sharing Empathy- The ability to understand and accept another’s person’s reality, to accurately perceive
feelings, and to communicate understanding.

Seeking Clarification- Asking patient for clarification when they say something confusing or unclear is
important. To make sure they understand what’s actually being said and can help patient process the
idea more thoroughly.

Using Silence- At times, its useful to not speak at all. Deliberate silence can give the patient an
opportunity to think through and process what comes next in the conversation.

Restating- Repeating to the patient what you said believes to be the main point that the patient is trying
to communicate; encourages the patient to offer additional information.

Sharing Feelings- This can help the patient express emotions by making observations, acknowledging
feelings, and encouraging communication, giving permission to express “negative” feelings.

Teamwork and Collaboration

• Primary care physician: An obstetrician is a doctor who specializes in pregnancy, childbirth, and
a woman's reproductive system. Although other doctors can deliver babies, many women see an
obstetrician, also called an OB/GYN.

• Nursing professionals: A clinical nurse specialist, nurse practitioner, or registered nurse might be
involved in the care of HIV patients. The nurse can provide information, counseling, or practical
assistance. Nurses help in adjusting the diagnosis, maintaining general good health, proper giving
medication, monitoring side effects, and communicating healthcare providers.

• Pharmacist: Pharmacist dispense prescription drugs from a drugstore(pharmacy). They focus on

giving safe and effective medication use. They keep careful records and help you keep track of your
drugs, avoid allergic reactions or interactions between drugs, package your drugs in blister packs for
ease of use, and provides useful information in taking your drugs regularly without any missed doses.

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• Medical technologist: Is an allied health professional that analyzes and tests body fluids and
tissues. They are responsible in maintaining and operating complex analyzers that are used in laboratory
and ensuring the laboratory results of each patient accurately and timely.

• Nutritionist and dieticians: They are responsible in maintaining a balance and healthy diet.
Dieticians can teach the patients how to prepare nutritious meals that can help in weight management
and reduce stress. They can help HIV patients to stay healthy despite their medical condition, reduce
harm, and give the right balance of food for the body.

• Medical technologist: Is an allied health professional that analyzes and tests body fluids and
tissues. They are responsible in maintaining and operating complex analyzers that are used in laboratory
and ensuring the laboratory results of each patient accurately and timely.

Ethico Moral-Legal Responsibility

ETHICO-MORAL

· Beneficence – Which asserts an obligation to confer benefit through a balance of benefit and
harm, and autonomy, which asserts an obligation to respect the choices of the pregnant woman within
the context of standard prenatal care. The principle of beneficence requires the balancing of the
physician from situation to situation.

· Autonomy - Has to a large degree been institutionalized within modern health care through the
idea of informed consent. Informed consent is required to ensure respect for autonomy; however,
respecting patients as persons requires more than informed consent.

· Non-Maleficence - Require the physician to objectively assess therapeutic options and

implement those that will most offer the patient the greatest balance of benefit over risk.

· Justice - This principle must be more far-sighted and look not only to who should benefit, but
also who should bear the burden. This approach is a form of distributive justice. Simply stated, this
principle requires that distribution of goods and services, including access to clinical trials are fair.

Enabling competencies

Management of resources and environment/Records management

• Provide a calm, and peaceful environment for patient

• Keep patient occupied and interested in things to avoid depression

• Manage and minimize stress by providing a calm, quiet atmosphere that is conducive to rest and
relaxation.

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• Encourage an open atmosphere for family and friends to be available for patient to be able to
verbalize feelings

• Try lighting, low-impact, non-straining exercises like walking.

Enhancing competencies

Mobile Health Solutions for Hypertensive Disorders in Pregnancy: Scoping Literature Review

Corresponding Author:

Octavio Rivera-Romero, PhD

Department of Electronic Technology

Universidad de Sevillaavda.

ABSTRACT

Background: Hypertensive disorders are the most common complications during pregnancy, occurring in
5% to 11% of pregnancies; gestational hypertension and preeclampsia are the leading causes of
perinatal and maternal morbidity and mortality, especially in low- and middle-income countries (LMIC)
where maternal and perinatal mortality ratios are still high. Pregnant women with hypertensive
disorders could greatly benefit from mobile health (mHealth) solutions as a novel way to identify and
control early symptoms, as shown in an increasing number of publications in the field. Such digital
health solutions may overcome access limiting factors and the lack of skilled medical professionals and
finances commonly presented in resource-poor environments.

Objective: The aim of this study was to conduct a literature review of mHealth solutions used as support
in hypertensive disorders during pregnancy, with the objective to identify the most relevant protocols
and prototypes that could influence and improve current clinical practice.

Methods: A methodological review following a scoping methodology was conducted. Manuscripts

published in research journals reporting technical information of mHealth solutions for hypertensive
disorders in pregnancy were included, categorizing articles in different groups: Diagnosis and
Monitoring, mHealth Decision Support System, Education, and Health Promotion, and seven research
questions were posed to study the manuscripts.

Results: The search in electronic research databases yielded 327 articles. After removing duplicates, 230
articles were selected for screening. Finally, 11 articles met the inclusion criteria, and data were
extracted from them. Very positive results in the improvement of maternal health and acceptability of
solutions were found, although most of the studies involved a small number of participants, and none
were complete clinical studies. Accordingly, none of the reported prototypes were integrated in the

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different health care systems. Only 4 studies used sensors for physiological measurements, and only 2
used blood pressure sensors despite the importance of this physiological parameter in the control of
hypertension. The reported mHealth solutions have great potential to improve clinical practice in areas
lacking skilled medical professionals or with a low health care budget, of special relevance in LMIC,
although again, no extensive clinical validation has been carried out in these environments.

Conclusions: mHealth solutions hold enormous potential to support hypertensive disorders during
pregnancy and improve current clinical practice. Although very positive results have been reported in
terms of usability and the improvement of maternal health, rigorous complete clinical trials are still
necessary to support integration in health care systems. There is a clear need for simple mHealth
solutions specifically developed for resource-poor environments that meet the United Nations
Sustainable Development Goal (SDG); of enormous interest in LMIC.

Pregnancy-Induced Hypertensive Disorders before and after a National Economic Collapse: A

Population Based Cohort Study

Védís Helga Eiríksdóttir , Unnur Anna Valdimarsdóttir, Tinna Laufey Ásgeirsdóttir,

Abstract

Background

Data on the potential influence of macroeconomic recessions on maternal diseases during pregnancy
are scarce. We aimed to assess potential change in prevalence of pregnancy-induced hypertensive
disorders (preeclampsia and gestational hypertension) during the first years of the major national
economic recession in Iceland, which started abruptly in October 2008.

Methods and Findings

Women whose pregnancies resulted in live singleton births in Iceland in 2005–2012 constituted the
study population (N = 35,211). Data on pregnancy-induced hypertensive disorders were obtained from
the Icelandic Medical Birth Register and use of antihypertensive drugs during pregnancy, including β-
blockers and calcium channel blockers, from the Icelandic Medicines Register. With the pre-collapse
period as reference, we used logistic regression analysis to assess change in pregnancy-induced

18
hypertensive disorders and use of antihypertensives during the first four years after the economic
collapse, adjusting for demographic and pregnancy characteristics, taking aggregate economic indicators
into account. Compared with the pre-collapse period, we observed an increased prevalence of
gestational hypertension in the first year following the economic collapse (2.4% vs. 3.9%; adjusted odds
ratio [aOR] 1.47; 95 percent confidence interval [95%CI] 1.13–1.91) but not in the subsequent years. The
association disappeared completely when we adjusted for aggregate unemployment rate (aOR 1.04;
95% CI 0.74–1.47). Similarly, there was an increase in prescription fills of β-blockers in the first year
following the collapse (1.9% vs.3.1%; aOR 1.43; 95% CI 1.07–1.90), which disappeared after adjusting for
aggregate unemployment rate (aOR 1.05; 95% CI 0.72–1.54). No changes were observed for
preeclampsia or use of calcium channel blockers between the pre- and post-collapse periods.

Conclusions

Our data suggest a transient increased risk of gestational hypertension and use of β-blockers among
pregnant women in Iceland in the first and most severe year of the national economic recession.

Personal and Professional Development

In order for health care team to develop their knowledge, attitude and skills about PIH

• Read journals for the latest updates about intervention and management of Preeclampsia.

• The nurse should undergo training to develop their skills in giving care to the pregnant women
with preeclampsia or hypertension.

• Prioritizing goals so that one can determine what is important and what is not

• The nurse must recognize his/her strength, weakness, limitation and demonstrate a
commitment to lifelong learning through self reflection and inquiry to identify learning needs

• Develop knowledge and skills by attending conventions and seminars concerning Preeclampasia.

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IX. IMPLICATIONS/INSIGHTS

Nursing Education

The knowledge gain from the classroom is very important because students are being
taught on how to know what are the classic signs and symptoms of pregnancy induced hypertension. It
will help the nursing students on what to if ever their patient has one.

Nursing Management

Nursing actions are implemented for the purpose of promotion, protection, recovery
and rehabilitation of the patient. The nursing students assist the patient on ways how to manage the
disease. Be the one to support the patient for fast recovery , encourage both the patient and folks and
to ensure the safety of both the mother and the fetus until delivery of the baby .

Nursing Practice

Clinical practice is important because as a nurse we continue to learn everyday and be

up to date for the safety of our client. Attending seminars etc are important to gain more knowledge
and skills for improvement of skills.

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BIBLIOGRAPHY

https://my.clevelandclinic.org/health/diseases/4497-pregnancy-induced-hypertension/management-
and-treatment

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0138534

Eiríksdóttir VH, Valdimarsdóttir UA, Ásgeirsdóttir TL, Hauksdóttir A, Lund SH, Bjarnadóttir RI, et al.
(2015) Pregnancy-Induced Hypertensive Disorders before and after a National Economic Collapse: A
Population Based Cohort Study. PLoS ONE 10(9): e0138534.
https://doi.org/10.1371/journal.pone.0138534

https://mhealth.jmir.org/2018/5/e130/?utm_source=dlvr.it&utm_medium=facebook

https://www.flashcardmachine.com/nclex-3000-obanteintrapartumpreeclampsia.html

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POST TEST:

1.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?

A) Oligohydramnios

B) Preeclampsia

C) Post-term labor

D) Chorioamnionitis

Ans: B

Rationale :

Women with multiple gestations are at high risk for preeclampsia, preterm labor, hydramnios,
hyperemesis gravidarum, anemia, and antepartal hemorrhage. There is no association between multiple
gestations and the development of chorioamnionitis.

2. A 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 client is having an adverse
effect associated with this drug?

A) Gastrointestinal bleeding

B) Blurred vision

C) Tachycardia

D) Sweating

Ans: C

Rationale:

Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation,
tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal
bleeding, blurred vision, or sweating. Magnesium sulfate may cause sweating.

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3.After reviewing a client's history, which factor would the nurse identify as placing her at risk for
gestational hypertension?

A) Mother had gestational hypertension during pregnancy.

B) Client has a twin sister.

C) Sister-in-law had gestational hypertension.

D) This is the client's second pregnancy.

Ans: A

Rationale:

A family history of gestational hypertension, such as a mother or sister, is considered a risk factor for the
client. Having a twin sister or having a sister-in-law with gestational hypertension would not increase the
client's risk. If the client had a history of preeclampsia in her first pregnancy, then she would be at risk in
her second pregnancy.

4. The nurse is reviewing the laboratory test results of a pregnant client. Which one of the following
findings would alert the nurse to the development of HELLP syndrome?

A) Hyperglycemia

B) Elevated platelet count

C) Leukocytosis

D) Elevated liver enzymes

Ans: D

Rationale

HELLP is an acronym for hemolysis, elevated liver enzymes, and low platelets. Hyperglycemia or
leukocytosis is not a part of this syndrome.

5.Which of the following would the nurse have readily available for a client who is receiving magnesium
sulfate to treat severe preeclampsia?

A) Calcium gluconate

B) Potassium chloride

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C) Ferrous sulfate

D) Calcium carbonate

Ans: A

Rationale:

The antidote for magnesium sulfate is calcium gluconate, and this should be readily available in case the
woman has signs and symptoms of magnesium toxicity.

6.A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to
be discharged home about caring for herself. Which statement by the woman indicates a need for
additional teaching?

A) "I need to keep a close eye on how active my baby is each day."

B) "I need to call my doctor if my temperature increases."

C) "It's okay for my husband and me to have sexual intercourse."

D) "I can shower but I shouldn't take a tub bath."

Ans: C

Rationale:

The woman with preterm premature rupture of membranes should monitor her baby's activity by
performing fetal kick counts daily, check her temperature and report any increases to the health care
provider, not insert anything into her vagina or vaginal area, such as tampons or vaginal intercourse, and
avoid sitting in a tub bath.

7. A nurse is assessing a pregnant woman with gestational hypertension. Which of the following would
lead the nurse to suspect that the client has developed severe preeclampsia?

A) Urine protein 300 mg/24 hours

B) Blood pressure 150/96 mm Hg

C) Mild facial edema

D) Hyperreflexia

Ans: D

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Rationale :

Severe preeclampsia is characterized by blood pressure over 160/110 mm Hg, urine protein levels
greater than 500 mg/24 hours and hyperreflexia. Mild facial edema is associated with mild
preeclampsia.

8. A nurse suspects that a pregnant client may be experiencing abruption placenta based on assessment
of which of the following? (Select all that apply.)

A) Dark red vaginal bleeding

B) Insidious onset

C) Absence of pain

D) Rigid uterus

E) Absent fetal heart tones

Ans: A, D, E

Rationale:

Assessment findings associated with abruption placenta include a sudden onset, with concealed or
visible bleeding, dark red bleeding, constant pain or uterine tenderness on palpation, firm to rigid
uterine tone, and fetal distress or absent fetal heart tones.

9.A nursing student is reviewing an article about preterm premature rupture of membranes. Which of
the following would the student expect to find as factor placing a woman at high risk for this condition?
(Select all that apply.)

A) High body mass index

B) Urinary tract infection

C) Low socioeconomic status

D) Single gestations

E) Smoking

Ans: B, C, E

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Rationale :

High-risk factors associated with preterm PROM include low socioeconomic status, multiple gestation,
low body mass index, tobacco use, preterm labor history, placenta previa, abruptio placenta, urinary
tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.

10. Which of the following is the most serious adverse affect associated with oxytocin administration
during labor?

a. tetanic contractions

b. elevated blood pressure

c. early decelerations of FHR

d. water intoxication

Answer

a. tetanic contractions - are most serious adverse effect associated with oxytocin. When tetanic
contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture.

Rationale :

The client may be at risk for pulmonary edema if large amounts of oxytocin were given. This drug can
increase BP too. BUT, pulmonary edema and HTN aren't the most serious adverse effects. Early
decelerations of FHR aren't associated with oxytocin.

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