Severe Preeclampsia & Eclampsia Nursing Mastery: Diagnostic Criteria (Hypertension ≥160/110, Proteinuria, Oliguria), CNS Involvement (Hyperreflexia, Clonus, Scotomata), Epigastric/RUQ Pain & Hepatic Dysfunction, Pulmonary Edema, Magnesium Sulfate Therapy

Severe Preeclampsia & Eclampsia Nursing Mastery: Diagnostic Criteria (Hypertension ≥160/110, Proteinuria, Oliguria), CNS Involvement (Hyperreflexia, Clonus, Scotomata), Epigastric/RUQ Pain & Hepatic Dysfunction, Pulmonary Edema, Magnesium Sulfate Therapy (Therapeutic Levels & Toxicity), Seizure Precautions & Airway Management, HELLP Syndrome (Hemolysis, Elevated Liver Enzymes, Low Platelets), Renal Impairment (BUN/Creatinine, 24-hr Protein), SBAR Prioritization, Fetal Monitoring, Oxygenation, Fluid Restriction, Postpartum Management, and Maternal–Fetal Complications Exam Questions Verified and Complete with A+ Graded Rationales Latest Updated 2026 PRE which of the entries on a pts medical record are evidence of the diagnosis of severe preeclampsia. SATA -Scotomata -Epigastric pain -Oliguria - 3 lb weight gain in 1 week -blood pressure 182/116 PRE which of the following need to be implemented when a pt with severe preeclampsia is admitted to the hospital. SATA -seizure precaustions -reduced stimulation -bed rest -dim light Rationale: 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 central nervous system irritability. Having frequent visitors doesn't create a relaxing environment for the patient. PRE what are the Priorities of care if a pregnant woman experiences an eclamptic seizure? STAT -Administer O2 -protect the pt from injury -clear airway Rationale: 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. PRE Pts with severe preeclampsia are at risk for developing acute pulmonary edema. What can the nurse do to prevent the development of this condition? control the rate of administration of IV fluids Rationale: It is important to carefully monitor IV infusion to achieve the delicate balance between keeping the patient well hydrated and preventing acute pulmonary edema. PRE what is the primary indication for the administration of magnesium sulfate to the pt with severe preeclampsia? preventing eclamptic seizures Rationale: 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. PRE which of the following findings from the nurse's assessment of the pt with severe preeclampsia would indicate central nervous system involvement? SATA -Visual changes -4+ deep tendon reflexes -positive clonus Rationale: Hyperactive reflexes, presence of clonus, and visual changes are all signs of central nervous system involvement. The absence of DTRs and negative clonus are not significant findings in the patient with preeclampsia.. Pre when reviewing a pts admission orders the nurse notes that the following lab studies have been ordered: BUN, BUN/CR ratio, and 24 urine protein. The results of these tests will provide info about the function of which organ? kidneys Rationale: All of these lab tests provide data to evaluate the patient's renal function, or the status of the kidneys. Liver function would be evaluated with liver function tests (LFTs), and placenta function would be evaluated with a human placental lactogen (HPL) level, a urine estriol test, or a fetal monitoring strip. PRE which of the following are signs of magnesium toxicity in a pt? SATA -Hyporeflexia -Respiratory depression -CNS depression Rationale: Magnesium toxicity causes depression of the central nervous system. Patients become lethargic and unresponsive, experience respiratory depression, and their muscles become flaccid (hyporeflexic). Urine production decreases with magnesium toxicity. Visual changes are related to changes in perfusion to the cerebral cortex/optic nerve and not the administration of magnesium. PRE to assess for clonus the nurse briskly dorsiflexes the pts foot and then releases it. What would a positive response look like? Jerky, rapid contraction of the ankle and foot Rationale: A positive finding is the rapid, jerky contraction of the ankle and foot in response to the dorsiflexion performed by the nurse. PRE what is the therapeutic blood level for a pt receiving an IV infusion of magnesium sulfate? 4-7 mEq/L Rationale: A therapeutic level is between 4 and 7 mEq/L. Levels of 8 mEq/L or greater are toxic and the patient will begin to demonstrate symptoms of central nervous system depression. POST a pt wit preeclampsia is admitted with vital signs as follows: temp 98.6, HR 110, RR 28, BP182/116, SpO2 92%. The fetal heart rate is 150 bpm. Which of the following interventions would the nurse implemen