Chapter 27: Hypertensive Disorders Lowdermilk: Maternity & Women’s Health Care, 11th Edition

TEST BANK FOR MATERNITY & WOMEN’S HEALTH CARE 11TH EDITION BY LOWDERMILK Chapter 27: Hypertensive Disorders Lowdermilk: Maternity & Women’s Health Care, 11th Edition 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 CORRECT ANSWER: 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. DIF: Cognitive Level: Analyze REF: p. 660 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 2. The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the woman‘s latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotrCORRECT ANSWERaminase (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 CORRECT ANSWER: 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. DIF: Cognitive Level: Understand REF: p. 657 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 CORRECT ANSWER: 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. DIF: Cognitive Level: Apply REF: p. 666 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 CORRECT ANSWER: 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 magnesium sulfate. In addition, calcium gluconate, 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. DIF: Cognitive Level: Apply REF: p. 664 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. Abruptio placentae CORRECT ANSWER: D Uterine tenderness in the presence of increasing tone may be the earliest sign of abruptio placentae. 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. DIF: Cognitive Level: Understand REF: p. 662 TOP: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity