Chapter 27: Hypertensive Disorders
MULTIPLE CHOICE
1. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is
of greatest concern to the nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. Dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day
ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A
dipstick value of 3+ alerts the nurse that additional testing or assessment should be
performed. A 24-hour urine collection is preferred over dipstick testing attributable to
accuracy. Generally, hypertension is defined as a BP of 140/90 mm Hg or an increase in
systolic pressure of 30 mm Hg or diastolic pressure of 15 mm Hg. Preeclampsia may be
demonstrated as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many
normal pregnancies, as well as in women with preeclampsia. Therefore, the presence of
edema is no longer considered diagnostic of preeclampsia.
PTS: 1 DIF: Cognitive Level: Analyze
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
2. The labor of a pregnant woN mUanRw
SiIthNpGreTecBla.mCpO
siaMis going to be induced. Before initiating
the oxytocin infusion, the nurse reviews the woman’s latest laboratory test findings, which
reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level,
and a falling hematocrit. The laboratory results are indicative of which condition?
a. Eclampsia
b. Disseminated intravascular coagulation (DIC) syndrome
c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP)
syndrome
d. Idiopathic thrombocytopenia
ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that
involves hepatic dysfunction characterized by hemolysis (H), elevated liver (EL) enzymes,
and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a
potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is
the presence of low platelets of unknown cause and is not associated with preeclampsia.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
3. A woman with preeclampsia has a seizure. What is the nurse’s highest priority during a
seizure?
a. To insert an oral airway
b. To suction the mouth to prevent aspiration
, c. To administer oxygen by mask
d. To stay with the client and call for help
ANS: D
If a client becomes eclamptic, then the nurse should stay with the client and call for help.
Nursing actions during a convulsion are directed toward ensuring a patent airway and client
safety. Insertion of an oral airway during seizure activity is no longer the standard of care.
The nurse should attempt to keep the airway patent by turning the client’s head to the side to
prevent aspiration. Once the seizure has ended, it may be necessary to suction the client’s
mouth. Oxygen is administered after the convulsion has ended.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe
preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs:
temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute,
BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client
complains, “I’m so thirsty and warm.” What is the nurse’s immediate action?
a. To call for an immediate magnesium sulfate level
b. To administer oxygen
c. To discontinue the magnesium sulfate infusion
d. To prepare to administer hydralazine
ANS: C
Regardless of the magnesium level, the client is displaying the clinical signs and symptoms
of magnesium toxicity. The first action by the nurse should be to discontinue the infusion of
NUn,RcSalcIN
magnesium sulfate. In additio GTglucon
ium B.CO ate, the antidote for magnesium, may be
administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension
in severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than
160 mm Hg or a diastolic BP higher than 110 mm Hg.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor
and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2
minutes, dark red vaginal bleeding, and a tense, painful abdomen. Which clinical change
does the nurse anticipate?
a. Eclamptic seizure
b. Rupture of the uterus
c. Placenta previa
d. Placental abruption
ANS: D
, Uterine tenderness in the presence of increasing tone may be the earliest sign of placental
abruption. Women with preeclampsia are at increased risk for an abruption attributable to
decreased placental perfusion. Eclamptic seizures are evidenced by the presence of
generalized tonic-clonic convulsions. Uterine rupture exhibits hypotonic uterine activity,
signs of hypovolemia, and, in many cases, the absence of pain. Placenta previa exhibits
bright red, painless vaginal bleeding.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
6. A woman with worsening preeclampsia is admitted to the hospital’s labor and birth unit.
The physician explains the plan of care for severe preeclampsia, including the induction of
labor, to the woman and her partner. Which statement by the partner leads the nurse to
believe that the couple needs further information?
a. “I will help her use the breathing techniques that we learned in our childbirth
classes.”
b. “I will give her ice chips to eat during labor.”
c. “Since we will be here for a while, I’ll ask my mother, to bring our toddler to
visit.”
d. “I will stay with her during her labor, just as we planned.”
ANS: C
Arranging a visit with their toddler indicates that the partner does not understand the
importance of the quiet, subdued environment that is needed to prevent this condition from
worsening. Implementing breathing techniques is indicative of adequate knowledge related
to pain management during labor. Administering ice chips indicates an understanding of
nutritional needs during labNor. R
UStaySIing
husband’s support and is appropriate.
NGwitBh.hiCs paMrtner during labor demonstrates the
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity
7. The client is being induced in response to worsening preeclampsia. She is also receiving
magnesium sulfate. It appears that her labor has not become active, despite several hours of
oxytocin administration. She asks the nurse, “Why is this taking so long?” What is the
nurse’s most appropriate response?
a. “Since the magnesium is competing with the oxytocin, your labor is slowed.”
b. “I don’t know why it is taking so long.”
c. “The length of labor varies for different women.”
d. “Your baby is just being stubborn.”
ANS: A
Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor.
The amount of oxytocin needed to stimulate labor may be more than that needed for the
woman who is not receiving magnesium sulfate. The nurse should explain to the client the
effects of magnesium sulfate on the duration of labor. Although the length of labor varies
for different women, the most likely reason this woman’s labor is protracted is the tocolytic
effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of
labor.
MULTIPLE CHOICE
1. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is
of greatest concern to the nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. Dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day
ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A
dipstick value of 3+ alerts the nurse that additional testing or assessment should be
performed. A 24-hour urine collection is preferred over dipstick testing attributable to
accuracy. Generally, hypertension is defined as a BP of 140/90 mm Hg or an increase in
systolic pressure of 30 mm Hg or diastolic pressure of 15 mm Hg. Preeclampsia may be
demonstrated as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many
normal pregnancies, as well as in women with preeclampsia. Therefore, the presence of
edema is no longer considered diagnostic of preeclampsia.
PTS: 1 DIF: Cognitive Level: Analyze
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
2. The labor of a pregnant woN mUanRw
SiIthNpGreTecBla.mCpO
siaMis going to be induced. Before initiating
the oxytocin infusion, the nurse reviews the woman’s latest laboratory test findings, which
reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level,
and a falling hematocrit. The laboratory results are indicative of which condition?
a. Eclampsia
b. Disseminated intravascular coagulation (DIC) syndrome
c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP)
syndrome
d. Idiopathic thrombocytopenia
ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that
involves hepatic dysfunction characterized by hemolysis (H), elevated liver (EL) enzymes,
and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a
potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is
the presence of low platelets of unknown cause and is not associated with preeclampsia.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
3. A woman with preeclampsia has a seizure. What is the nurse’s highest priority during a
seizure?
a. To insert an oral airway
b. To suction the mouth to prevent aspiration
, c. To administer oxygen by mask
d. To stay with the client and call for help
ANS: D
If a client becomes eclamptic, then the nurse should stay with the client and call for help.
Nursing actions during a convulsion are directed toward ensuring a patent airway and client
safety. Insertion of an oral airway during seizure activity is no longer the standard of care.
The nurse should attempt to keep the airway patent by turning the client’s head to the side to
prevent aspiration. Once the seizure has ended, it may be necessary to suction the client’s
mouth. Oxygen is administered after the convulsion has ended.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe
preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs:
temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute,
BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client
complains, “I’m so thirsty and warm.” What is the nurse’s immediate action?
a. To call for an immediate magnesium sulfate level
b. To administer oxygen
c. To discontinue the magnesium sulfate infusion
d. To prepare to administer hydralazine
ANS: C
Regardless of the magnesium level, the client is displaying the clinical signs and symptoms
of magnesium toxicity. The first action by the nurse should be to discontinue the infusion of
NUn,RcSalcIN
magnesium sulfate. In additio GTglucon
ium B.CO ate, the antidote for magnesium, may be
administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension
in severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than
160 mm Hg or a diastolic BP higher than 110 mm Hg.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor
and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2
minutes, dark red vaginal bleeding, and a tense, painful abdomen. Which clinical change
does the nurse anticipate?
a. Eclamptic seizure
b. Rupture of the uterus
c. Placenta previa
d. Placental abruption
ANS: D
, Uterine tenderness in the presence of increasing tone may be the earliest sign of placental
abruption. Women with preeclampsia are at increased risk for an abruption attributable to
decreased placental perfusion. Eclamptic seizures are evidenced by the presence of
generalized tonic-clonic convulsions. Uterine rupture exhibits hypotonic uterine activity,
signs of hypovolemia, and, in many cases, the absence of pain. Placenta previa exhibits
bright red, painless vaginal bleeding.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
6. A woman with worsening preeclampsia is admitted to the hospital’s labor and birth unit.
The physician explains the plan of care for severe preeclampsia, including the induction of
labor, to the woman and her partner. Which statement by the partner leads the nurse to
believe that the couple needs further information?
a. “I will help her use the breathing techniques that we learned in our childbirth
classes.”
b. “I will give her ice chips to eat during labor.”
c. “Since we will be here for a while, I’ll ask my mother, to bring our toddler to
visit.”
d. “I will stay with her during her labor, just as we planned.”
ANS: C
Arranging a visit with their toddler indicates that the partner does not understand the
importance of the quiet, subdued environment that is needed to prevent this condition from
worsening. Implementing breathing techniques is indicative of adequate knowledge related
to pain management during labor. Administering ice chips indicates an understanding of
nutritional needs during labNor. R
UStaySIing
husband’s support and is appropriate.
NGwitBh.hiCs paMrtner during labor demonstrates the
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity
7. The client is being induced in response to worsening preeclampsia. She is also receiving
magnesium sulfate. It appears that her labor has not become active, despite several hours of
oxytocin administration. She asks the nurse, “Why is this taking so long?” What is the
nurse’s most appropriate response?
a. “Since the magnesium is competing with the oxytocin, your labor is slowed.”
b. “I don’t know why it is taking so long.”
c. “The length of labor varies for different women.”
d. “Your baby is just being stubborn.”
ANS: A
Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor.
The amount of oxytocin needed to stimulate labor may be more than that needed for the
woman who is not receiving magnesium sulfate. The nurse should explain to the client the
effects of magnesium sulfate on the duration of labor. Although the length of labor varies
for different women, the most likely reason this woman’s labor is protracted is the tocolytic
effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of
labor.
