vSim - Olivia Jones All Questions and Answers Complete
Which of the entries on a patient's medical record are evidence of the diagnosis of
severe preeclampsia? (Select all that apply.)
a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
e) Negative urine ketones
f) Scotomata
a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
f) Scotomata
All of these findings, except negative ketones, support the diagnosis. The urine finding
supportive of this diagnosis is the presence of protein.
Which of the following need to be implemented when a patient with severe
preeclampsia is admitted to the hospital? (Select all that apply.)
a) Television for entertainment
b) Bed rest in a left lateral lying position
c) Frequent visitors for diversion and support
d) Seizure precautions
e) Dim lighting
f) Reduced environmental stimulation
b) Bed rest in a left lateral lying position
d) Seizure precautions
e) Dim lighting
f) Reduced environmental stimulation
The environment needs to be quiet, darkened, and relaxing. Seizure precautions are
necessary for the potential development of eclampsia. The changing light intensity from
a television can aggravate CNS irritability. Having frequent visitors doesn't create a
relaxing environment for the patient.
What are the priorities of care if a pregnant woman experiences an eclamptic seizure?
(Select all that apply.)
a) Restrain the patient
b) Protect the patient from injury
c) Clear the airway
d) Insert a bite block to protect the tongue
e) Begin a cesarean birth immediately
f) Administer oxygen
, b) Protect the patient from injury
c) Clear the airway
f) Administer oxygen
The priorities are airway, oxygenation, and protection from injury. Trying to insert a bite
block or restraining a patient during a seizure may result in injury to the patient and the
provider. Birth is not initiated until the seizures are under control.
Patients with severe preeclampsia are at risk for developing acute pulmonary edema.
What can the nurse do to prevent the development of this condition?
a) Monitor the patient's SpO2 levels
b) Use the incentive spirometer every 2 hours
c) Administer oxygen continuously
d) Control the rate of administration of intravenous (IV) fluids
d) Control the rate of administration of intravenous (IV) fluids
It is important to carefully monitor IV infusion to achieve the delicate balance between
keeping the patient well hydrated and preventing acute pulmonary edema. The other
options will not impact the development of pulmonary edema.
What is the primary indication for the administration of magnesium sulfate to the patient
with severe preeclampsia?
a) Lowering maternal blood pressure
b) Preventing eclamptic seizures
c) Enhancing placental blood flow
d) Relaxing the uterus
b) Preventing eclamptic seizures
Magnesium works on the central nervous system and prevents eclamptic seizures in the
patient with severe preeclampsia. Sometimes magnesium is used as a tocolytic agent in
patients with pre-term labor, but that is not the indication in this situation.
Which of the following findings from the nurse's assessment of the patient with severe
preeclampsia would indicate central nervous system involvement? (Select all that
apply.)
a) Absent deep tendon reflexes (DTRs)
b) 4+ deep tendon reflexes (DTRs)
c) Negative clonus
d) Positive clonus
e) Visual changes
b) 4+ deep tendon reflexes (DTRs)
d) Positive clonus
e) Visual changes
Hyperactive reflexes, presence of clonus, and visual changes are all signs of CNS
Which of the entries on a patient's medical record are evidence of the diagnosis of
severe preeclampsia? (Select all that apply.)
a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
e) Negative urine ketones
f) Scotomata
a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
f) Scotomata
All of these findings, except negative ketones, support the diagnosis. The urine finding
supportive of this diagnosis is the presence of protein.
Which of the following need to be implemented when a patient with severe
preeclampsia is admitted to the hospital? (Select all that apply.)
a) Television for entertainment
b) Bed rest in a left lateral lying position
c) Frequent visitors for diversion and support
d) Seizure precautions
e) Dim lighting
f) Reduced environmental stimulation
b) Bed rest in a left lateral lying position
d) Seizure precautions
e) Dim lighting
f) Reduced environmental stimulation
The environment needs to be quiet, darkened, and relaxing. Seizure precautions are
necessary for the potential development of eclampsia. The changing light intensity from
a television can aggravate CNS irritability. Having frequent visitors doesn't create a
relaxing environment for the patient.
What are the priorities of care if a pregnant woman experiences an eclamptic seizure?
(Select all that apply.)
a) Restrain the patient
b) Protect the patient from injury
c) Clear the airway
d) Insert a bite block to protect the tongue
e) Begin a cesarean birth immediately
f) Administer oxygen
, b) Protect the patient from injury
c) Clear the airway
f) Administer oxygen
The priorities are airway, oxygenation, and protection from injury. Trying to insert a bite
block or restraining a patient during a seizure may result in injury to the patient and the
provider. Birth is not initiated until the seizures are under control.
Patients with severe preeclampsia are at risk for developing acute pulmonary edema.
What can the nurse do to prevent the development of this condition?
a) Monitor the patient's SpO2 levels
b) Use the incentive spirometer every 2 hours
c) Administer oxygen continuously
d) Control the rate of administration of intravenous (IV) fluids
d) Control the rate of administration of intravenous (IV) fluids
It is important to carefully monitor IV infusion to achieve the delicate balance between
keeping the patient well hydrated and preventing acute pulmonary edema. The other
options will not impact the development of pulmonary edema.
What is the primary indication for the administration of magnesium sulfate to the patient
with severe preeclampsia?
a) Lowering maternal blood pressure
b) Preventing eclamptic seizures
c) Enhancing placental blood flow
d) Relaxing the uterus
b) Preventing eclamptic seizures
Magnesium works on the central nervous system and prevents eclamptic seizures in the
patient with severe preeclampsia. Sometimes magnesium is used as a tocolytic agent in
patients with pre-term labor, but that is not the indication in this situation.
Which of the following findings from the nurse's assessment of the patient with severe
preeclampsia would indicate central nervous system involvement? (Select all that
apply.)
a) Absent deep tendon reflexes (DTRs)
b) 4+ deep tendon reflexes (DTRs)
c) Negative clonus
d) Positive clonus
e) Visual changes
b) 4+ deep tendon reflexes (DTRs)
d) Positive clonus
e) Visual changes
Hyperactive reflexes, presence of clonus, and visual changes are all signs of CNS
