The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station. 1. In reviewing Jennie’s history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Jennie’s risk of developing preeclampsia? (Select all that apply.) A) Molar pregnancy and history of preeclampsia in previous pregnancy. B) Familial history.
C) History of pounding headache, low socioeconomic status. D) Preexisting medical or genetic condition, like Factor V Leiden. E) Nulliparity
2. To accurately assess this client’s condition, what information from the prenatal record is most important for the nurse to obtain? A) Pattern and number of prenatal visits. B) Prenatal blood pressure readings. C) Prepregnancy weight. D) Jennie’s Rh factor.
Pathophysiology of Preeclampsia There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm. Function in organs such as the placenta, liver, brain, and kidneys can be depressed as much as 40 to 60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen. The edema of preeclampsia is generalized. Virtually all organ systems are affected by this disease, and the mother and fetus suffer increasing risk as the disease progresses.
Preeclampsia develops after 20 weeks gestation in a previously normotensive woman. Elevated blood pressure is frequently the first 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 often present. Preeclampsia progresses along a continuum from mild to severe preeclampsia, HELLP syndrome, or eclampsia. A client may present 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.
B) Increased perfusion to the brain. C) Severe anxiety. D) Retinal arteriolar spasms.
Jennie’s sister is very concerned about the swelling (edema) in her sister’s face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider will prescribe some of “those water pills” (diuretics) to help get rid of the excess fluid. 4. Which response by the nurse is correct?
A) “That is a very good idea. I will relay it to the healthcare provider when I call.” B) “I’m sorry, but it is not the family’s place to make suggestions about medical treatment.” C) “Let me explain to you about the effect of diuretics on pregnancy.” D) “Have you by any chance given your sister water pills that belong to someone else?” Admission to the Labor and Delivery 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, oxytocin (Pitocin) 2 mu/min, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital signs, and DTRs. 5. After the nurse establishes IV placement, she collects a bag of D5LR for the oxytocin (Pitocin), which is available in 20 units in 1000 cc D5LR. The order from the health care provider is oxytocin (Pitocin) 2 mu/min to augment labor. Calculate the following drip rate for the oxytocin (Pitocin). (Enter the numerical value only. If rounding is required, round to the whole number.)
6. While the nurse is awaiting the lab results, which nursing intervention has the highest priority? A) Teach Jennie the rationale for bedrest. B) Monitor Jennie for signs of dehydration. C) Educate the client about dietary restrictions. D) Observe Jennie for CNS changes.
7. Which technique should the nurse use when evaluating Jennie’s blood pressure while she is on bedrest? A) Have Jennie lay supine and take the blood pressure on the left arm. B) Have Jennie lie in a lateral position and take the blood pressure on the dependent arm. C) Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. D) Have Jennie stand briefly and take the blood pressure on the right arm. The nurse performs a nonstress test to evaluate fetal well-being.
8. When performing a nonstress test (NST), the nurse will be assessing for which parameters? A) Accelerations of the fetal heart rate in response to fetal movement. B) Late decelerations of the fetal heart rate in response to fetal movement. C) Accelerations of the fetal heart rate in response to uterine contractions. D) Late decelerations of the fetal heart rate in response to uterine contractions.
HELLP Syndrome At 0800, physical assessment and labs reveal the following: the client is still complaining of a headache but the epigastric pain has slightly decreased. While the client is resting in a left lateral position, the vital signs are BP 146/94, P 75, R 18. Hyperreflexia continues with one beat of clonus. The baseline fetal heart rate is 140 with moderate variability and no decelerations. Since completion of a reactive nonstress test, no further accelerations have occurred.
Lab results include: hemoglobin – 13.1 g/dl, hematocrit – 40.5 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.
9. 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. B) Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count