Lowdermilk 11th Ed. Chapter 27:
Hypertensive Disorders
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 - answers✔✔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 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 - answers✔✔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 - answers✔✔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 - answers✔✔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,
Hypertensive Disorders
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 - answers✔✔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 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 - answers✔✔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 - answers✔✔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 - answers✔✔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,
