2024 HESI Case Study Preeclampsia Ashley Cash

1. In reviewing Ashley's history, the RN 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 Ashelys risk of developing preeclampsia? (Select all) - ANSWER - Familial history -Preexisting medical or genetic condition, such as Factor V Leiden -Nulliparity 2. To accurately assess this client's condition, what information from the prenatal record is most important for the RN to obtain? - ANSWER Prenatal blood pressure reading 3. What is the pathophysiology responsible for Ashely's complaint of a pounding headache and the elevated DTRs? - ANSWER cerebral edema 4. Ashely's sister is concerned about the edema in her sister's face and hands. She asks the RN if the (HCP) will prescribe some of "those water pills" (diuretics) to help get rid of the excess fluid. Which response by the RN is correct? - ANSWER "Let me explain to you about the effect of diuretics on pregnancy. 5. After the RN establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000mL D5LR. The order from the HCP is oxytocin 2mU/min to augment labor. Calculate the drip rate for the oxytocin. (Whole number) - ANSWER 6 1/1000 x 2mu/1hr= 2000/20000= 0.10 x 60 min= 6mL/hr 6. While the RN is awaiting the lab results to determin if Ashely has elevatioin in liver function, diminished kidney function, or altered coagulopathies, which question should the RN ask Ashely? (Select all) - ANSWER -"Do you have a Dizziness? -Do you have blurry vision?" -"Do you have abdominal pain" -"Do you have shortness of breath or chest discomfort?" 7. Which technique should the RN use when evaluating Ashely's blood pressure while Ashely is on bedrest? - ANSWER Have Ashely lie in a lateral position and take the blood pressure on the dependent arm 8. When performing a nonstress test, the RN will be assessing for which parameters? - ANSWER It evaluates the heart rate of the fetus in response to its own movement. 9. If Ashely had HELLP syndrome, which lab results would the RN expect to see? - ANSWER Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, decrease creatinine clearance. 10. The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced RN? - ANSWER A 35-year-old gravida 3, para 2, with HELLP syndrome 11. What is the primary action of magnesium sulfate when given in preeclampsia? - ANSWER A CNS depressant 12. What information should be included in the client family teaching of magnesium sulfate? - ANSWER Magnesium is excreted in the urine, so the nurse will closely monitor the urine output. 13. If magnesium toxicity is suspected, which medication should the nurse prepare to administer? - ANSWER Calcium gluconate 14. The nurse asks Ashley if the HCP has discussed the labor and delivery processes, potential complications, and the management of those complications with her and if she understands them. Ashley replies, "I think so," and then asks for a pen. Which action should the nurse take? - ANSWER Ask Ashley to explain what she understands about the procedures 15. Ashley's husband offers to sign the consent forms since she isn't feeling well right now. Which response by the RN is correct? - ANSWER "Ashely should sign the consent forms herself since she is the one receiving the care." 16. Ashely asks why the magnesium sulfate was increased. What explanation should the RN provide? - ANSWER The magnesium is being excreted through the kidneys 17. When the RN evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change? - ANSWER The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated. 18. At 0930 Ashely's sister rings the call bell and yells, "Come quickly, Jennie is shaking all over." The RN determines that Jennie is experiencing an eclamptic seizure. Which nursing intervention takes priority? - ANSWER Turn Ashely onto her side and place a pillow behind her to stabilize the position 19. The RN recognizes what type of periodic fetal heart rate change that is occurring? - ANSWER Late decelerations 20. What should the RN do next to ensure intrauterine resuscitation? - ANSWER Implement a prescribed fluid bolus to improve maternal blood volume 21. How should Ashley be positioned to receive epidural? - ANSWER Seated on the edge of bed, slightly bent forward with legs dangling 22. For which complication is Ashley most at risk following the epidural with a local anesthestic, such as bupivacaine or ropivacaine? - ANSWER Hypotension 23. At 1130 Ashely complains of rectal pressure and an urge to push. The RN reviews the proper pushing technique with Jennie and her partner. What should the RN tell Jennie? - ANSWER When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides. 24. The NICU RN anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate? - ANSWER Hyporeflexia and decreased respirations 25. Ashley remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released Ashley from the postanesthesia care unit. Which room and nursing staff assignments should be made for Ashely? - ANSWER Move Ashely to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her 26. Ashely's partner asks if some friends can come and watch television with him now that the baby has been born. Which response by the RN is most appropriate? - ANSWER "Your partner is still at risk for complications, so visitors are limited to family members, and only for a short period of time."