In Reviewing Ashleys History the Rn Is Correct in Concluding
At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), bloated hands and face for 2 days, and epigastric pain described equally bad heartburn. Her sister tells the nurse, "I felt similar that when I had toxemia during my pregnancy. " Access assessment past the nurse reveals: today's weight 182 pounds, T 99. 1° F, P 76, R 22, BP 138/88, iv+ pitting edema, and 3+ poly peptide in the urine. Heart rate is regular, and lung sounds are articulate.
Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus. The nurse applies the external fetal monitor, which shows a baseline fetal heart charge per unit of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal test and finds that the cervix is 1 cm dilated and l% effaced, with the fetal caput at a -ii station. 1. In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder considering of her age (fifteen).
Which other factors add together to Jennie'southward 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 (commencement trimester vaginal bleeding, size/appointment discrepancy, or excessive nausea and vomiting), nor has she had any previous pregnancies (gravida ane). B) Gravidity, familial history. CORRECT Jennie is under 17 years of age, is pregnant for the 1st time, and has a sis with a history of toxemia, which is an old term for preeclampsia that some clients may notwithstanding use.
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C) History of pounding headache, low socioeconomic status. Incorrect While historic period and low socioeconomic status (SES) are risk factors, Jennie's SES is unknown. A pounding headache is a symptom, not a risk factor. D) Depression socioeconomic status (SES), history of pedal edema. INCORRECT Although age and low SES are risk factors, this customer's SES is unknown. Pedal edema is common in pregnancy after 32-weeks. 2. To accurately appraise this client's condition, what information from the prenatal record is most of import for the nurse to obtain? A) Pattern and number of prenatal visits. Wrong
Information technology is of import to have early on and consistent prenatal intendance, but this information will not help in the cess of this customer's condition. B) Prenatal blood pressure readings. Right The client'due south BP (138/88) is below the guideline that indicates balmy preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of 140/90 taken on two occasions 6 hours apart. However, Jennie'due south reading is significant if it is an increase of xxx mm systolic or fifteen mm diastolic from her prenatal levels, particularly in combination with proteinuria and hyperuricemia (uric acrid of half dozen mg/dl or more).
Blood pressure usually remains the aforementioned during the showtime trimester. Both systolic and diastolic then subtract gradually upwardly to 20-weeks gestation. At twenty weeks of gestation, the blood pressure begins to gradually increment and return to 1st trimester levels at term. C) Prepregnancy weight. Incorrect The nurse should compare today's weight to Jennie'south nigh recently obtained previous weight, non to the prepregnancy weight. A weight gain of ;two pounds per week is indicative of mild preeclampsia. D) Jennie'south Rh gene. Incorrect
While the Rh factor of the mother is of import in determining the demand for rubber Rh immune globulin (RhoGAM) at 28-weeks and subsequently birth, information technology is not the nearly 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 nascence to determine if another dose of RhoGam is needed. Pathophysiology of Preeclampsia There is no definitive cause of preeclampsia, just the pathophysiology is singled-out. The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm.
Function in organs such as the placenta, liver, brain, and kidneys tin exist depressed as much equally 40 to threescore%. Equally fluid shifts out of the intravascular compartment, a subtract in plasma volume and subsequent increase in hematocrit is seen. The edema of preeclampsia is generalized. Near all organ systems are affected past this disease, and the female parent and fetus suffer increasing risk every bit the disease progresses. Preeclampsia develops later 20 weeks gestation in a previously normotensive woman. Elevated claret pressure is oft the kickoff 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 ofttimes present. Preeclampsia progresses along a continuum from balmy to severe preeclampsia, HELLP syndrome, or eclampsia. A client may nowadays 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 equally 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 feet. Wrong While Jennie may be very broken-hearted, 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 affliction.
Jennie's sis is very concerned about the swelling (edema) in her sister's confront and hands considering it seems to exist worsening rapidly. She asks the nurse if the healthcare provider will prescribe some of "those water pills" (diuretics) to assistance get rid of the excess fluid. iv. Which response by the nurse is correct? A) "That is a very good idea. I volition relay information technology 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 identify to make suggestions about medical treatment. " INCORRECT While information technology is not inappropiate for family unit members to make suggestions, this respond is not sensitive to the sister'due south want 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 retentivity earlier (for example, in cardiac disease), but may non be enlightened of how diuretics bear on pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood book.
In the case of the preeclamptic client, this is especially dangerous because the disease has already acquired a volume arrears. In add-on, the diuretics disrupt normal electrolyte balance and stress kidneys that are already compromised past preeclampsia. The but time they are used is if the preeclamptic client also has middle failure, but this customer 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 exist construed as hostile and accusatory.
If the nurse believes further assessment is warranted, the nurse should enquire Jennie about any medication she has taken. Admission to the Labor and Commitment 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 console, 24-hour urine collection for protein and uric acrid, ice chips simply past mouth, nonstress test, hourly vital signs, and DTRs. v.
While pending 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 water ice chips simply and may already be hypovolemic. However, it is non the highest priority. C) Educate the customer about dietary restrictions. INCORRECT Since Jennie is currently taking ice chips only, this is non the most of import intervention at this fourth dimension. D) Observe Jennie for CNS changes.
Right Central Nervous Arrangement (CNS) changes such as severe headache, blurred vision, scotoma (spots earlier eyes), and photophobia indicate a worsening condition. 6. Which technique should the nurse use when evaluating Jennie's blood force per unit area while she is on bedrest? A) Have Jennie lay supine and take the claret pressure on the left arm. INCORRECT The significant client should not lie in the supine position because it puts her at take chances for vena cava pinch and subsequent supine hypotensive syndrome. B) Have Jennie lie in a lateral position and take the blood force per unit area on the dependent arm.
Right The lateral position supports placental perfusion. The lower (dependent) arm should exist positioned and then 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) Accept the customer sit in a chair at the bedside, and take the blood pressure level with her left arm at waist level. INCORRECT While sitting is an advisable 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 upwardly in a chair. D) Accept Jennie stand up briefly and have the blood pressure on the right arm. INCORRECT A standing blood force per unit area does not provide the most valid reading. In add-on, 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. vii. When performing a nonstress exam (NST), the nurse volition exist assessing for which parameters? A) Accelerations of the fetal center rate in response to fetal movement. CORRECT
The basis for the nonstress examination is that the normal fetus with an intact CNS volition respond to fetal movements by increasing its centre rate (episodic accelerations). A reactive examination is ane in which the fetus displays at least 2 accelerations of xv beats per minute that last for 15 seconds in a xx-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 motion. INCORRECT Late decelerations are a sign of uteroplacental insufficiency, and are assessed for in response to uterine contractions, not fetal motility.
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 ground for the nonstress test. D) Late decelerations of the fetal heart rate in response to uterine contractions. Incorrect Belatedly decelerations in response to uterine contractions are the basis for the contraction stress test. HELLP Syndrome At 0800, physical cess and labs reveal the following: the client is still lament of a headache but the epigastric hurting 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 out of clonus. The baseline fetal eye rate is 140 with moderate variability and no decelerations. Since completion of a reactive nonstress exam, no further accelerations have occurred. Lab results include: hemoglobin - 13. ane g/dl, hematocrit - twoscore. 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
Related Questions
on Preeclampsia Case Written report
Who is at hazard of preeclampsia?
Preeclampsia ordinarily occurs after the 34th week of gestation, just it can develop after the infant is delivered. Preeclampsia and eclampsia develop nearly ordinarily during the beginning pregnancy. Pregnant teens and women over 40 are at increased take chances. Eclampsia is the development of seizures in a woman with severe preeclampsia.
Does pre-eclampsia cause stroke?
Pre-eclampsia is considered ane of the major causes of stroke during pregnancy. The condition raises a pregnant woman'south stroke risk by iv times. All the same, just one per cent of women with severe high claret pressure suffer a stroke in the half-dozen weeks after they have given birth. Yet pre-eclampsia sufferers are more at chance of a stroke in later life.
What are the symptoms of preeclampsia, eclampsia,?
It is estimated that the prevalence of pre-eclampsia globally is 4.6% (95% CI two.7%-8.ii%) [ 5 ]. The prevalence of eclampsia globally is reported to be 0.3% [ 6 ].
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