N144 Week 5 Case Study - Preeclampsia
Study online at https://quizlet.com/_bkjfdd
1. Meet the Client
At 0600 a 42 year old primigravida client is brought to the Labor and Delivery
triage area by her sister. The client reports having a pounding headache for
the last 12 hours unrelieved by acetaminophen, swollen hands and face for 2
days, blurry vision, and epigastric pain described as bad heartburn. The client
expresses concern because her due date is not for four more weeks. Her sister
tells the nurse, "I felt like that when I had toxemia during my pregnancy."
Important to Know
1. Your first answer is the one that counts towards your score, but you'll be
prompted to try again if you get the wrong answer. When you get the right
answer, you'll go to the next section.
2. If you choose to re-take a Case Study, you will no longer be able to see your
previous score.:
2. Section 1
Nursing Process: Assessment
Admission assessment by the nurse reveals the following: today's weight 182
pounds, T 99. 1° F (37.3o C), P 76 beats/min, R 22 breaths/min, BP 138/88
mmHg, 4+ pitting edema, and 3+ proteinuria. Heart rate is regular, and lung
sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and
4+ patellar with 1 beat of ankle clonus.
Click for Image
Click for Image
The nurse applies the external fetal monitor, which shows a baseline fetal
heart rate of 130, short-term variability present, 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.:
3. Question 1 of 30
In reviewing the client's history, the nurse is correct in concluding that she
is at risk of developing a hypertensive disorder. Which other factors add to
her risk of developing preeclampsia? (Select all that apply. One, some, or all
options may be correct.)
Select all that apply
Nulliparity.
Familial history.
History of pounding headache.
Preexisting medical or genetic condition.
, N144 Week 5 Case Study - Preeclampsia
Study online at https://quizlet.com/_bkjfdd
Advanced maternal age.: Nulliparity.
Familial history.
Preexisting medical or genetic condition.
Advanced maternal age.
First pregnancy places a client at higher risk for preeclampsia than multiparity with
the same partner.
The client is older than 40 years of age and has a sister with a history of toxemia,
which is an old term for preeclampsia that some clients may still use.
Reasons for preeclampsia are unknown, but research shows that preexisting med-
ical conditions and genetic conditions put the client at higher risk for preeclampsia.
Age over 40 puts the client at increased risk of developing preeclampsia.
A pounding headache is a symptom, not a risk factor.
4. Question 2 of 30
To accurately assess this client's condition, what information from the prena-
tal record is most important for the nurse to obtain?
Pattern and number of prenatal visits.
Prenatal blood pressure readings.
Prepregnancy weight.
Client's Rh factor.: Prenatal blood pressure readings.
The client's blood pressure (BP) (138/88) is below the guideline that indicates mild
preeclampsia. Blood pressure parameters for mild preeclampsia include a reading
of 140/90 taken on two occasions 6 hours apart. However, the client's reading is
significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal
levels, particularly in combination with proteinuria, blurry vision, epigastric pain and
hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the
same during the first trimester. Both systolic and diastolic then decrease gradually
up to 20-weeks' gestation. At 20 weeks' gestation, the blood pressure begins to
gradually increase and return to 1st trimester levels at term.
It is important to have early and consistent prenatal care, but this information will not
help in the assessment of this client's condition.
The nurse should compare today's weight to the client's most recently obtained
, N144 Week 5 Case Study - Preeclampsia
Study online at https://quizlet.com/_bkjfdd
previous weight, not to the prepregnancy weight. A weight gain of more than 2
pounds per week is indicative of mild preeclampsia.
While the Rh factor of the mother is important in determining the need for prophy-
lactic Rh immune globulin (RhoGAM) at 28 weeks and after birth, it is not the most
important information at this time. All Rh negative women with negative indirect
Coomb's tests are given RhoGam prophylactically at 28 weeks and then evaluated
immediately after birth to determine if another dose of RhoGam is needed.
5. Section 2
Pathophysiology of Normal Pregnancy vs Preeclampsia
Preeclampsia develops after 20 weeks' gestation in a previously normotensive
woman. Elevated blood pressure is frequently the first sign of preeclampsia.
The client has a headache and blurred vision and also develops protein-
uria. 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 bed rest is often present. Preeclampsia progresses along
a continuum from mild to severe preeclampsia to eclampsia. A client may
present to the labor unit anywhere along that continuum.:
6. Question 3 of 30
What is the pathophysiology responsible for the client's complaint of a pound-
ing headache and the elevated DTRs?
Severe anxiety.
Cerebral edema.
Retinal arteriolar spasms.
Increased perfusion to the brain.: Cerebral edema.
As fluid leaks into the extravascular spaces, organ edema as well as peripheral
edema occurs. This, in conjunction with cortical brain spasms, causes headache,
increased deep tendon reflexes, and clonus.
While the client may be very anxious, this is not the pathophysiology involved.
These spasms are the cause of blurred vision and scotoma that often accompa-
ny worsening of the disease. The decreased perfusion to the brain causes the
headaches.
The hypovolemia that accompanies preeclampsia decreases perfusion to the major
organs.
Study online at https://quizlet.com/_bkjfdd
1. Meet the Client
At 0600 a 42 year old primigravida client is brought to the Labor and Delivery
triage area by her sister. The client reports having a pounding headache for
the last 12 hours unrelieved by acetaminophen, swollen hands and face for 2
days, blurry vision, and epigastric pain described as bad heartburn. The client
expresses concern because her due date is not for four more weeks. Her sister
tells the nurse, "I felt like that when I had toxemia during my pregnancy."
Important to Know
1. Your first answer is the one that counts towards your score, but you'll be
prompted to try again if you get the wrong answer. When you get the right
answer, you'll go to the next section.
2. If you choose to re-take a Case Study, you will no longer be able to see your
previous score.:
2. Section 1
Nursing Process: Assessment
Admission assessment by the nurse reveals the following: today's weight 182
pounds, T 99. 1° F (37.3o C), P 76 beats/min, R 22 breaths/min, BP 138/88
mmHg, 4+ pitting edema, and 3+ proteinuria. Heart rate is regular, and lung
sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and
4+ patellar with 1 beat of ankle clonus.
Click for Image
Click for Image
The nurse applies the external fetal monitor, which shows a baseline fetal
heart rate of 130, short-term variability present, 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.:
3. Question 1 of 30
In reviewing the client's history, the nurse is correct in concluding that she
is at risk of developing a hypertensive disorder. Which other factors add to
her risk of developing preeclampsia? (Select all that apply. One, some, or all
options may be correct.)
Select all that apply
Nulliparity.
Familial history.
History of pounding headache.
Preexisting medical or genetic condition.
, N144 Week 5 Case Study - Preeclampsia
Study online at https://quizlet.com/_bkjfdd
Advanced maternal age.: Nulliparity.
Familial history.
Preexisting medical or genetic condition.
Advanced maternal age.
First pregnancy places a client at higher risk for preeclampsia than multiparity with
the same partner.
The client is older than 40 years of age and has a sister with a history of toxemia,
which is an old term for preeclampsia that some clients may still use.
Reasons for preeclampsia are unknown, but research shows that preexisting med-
ical conditions and genetic conditions put the client at higher risk for preeclampsia.
Age over 40 puts the client at increased risk of developing preeclampsia.
A pounding headache is a symptom, not a risk factor.
4. Question 2 of 30
To accurately assess this client's condition, what information from the prena-
tal record is most important for the nurse to obtain?
Pattern and number of prenatal visits.
Prenatal blood pressure readings.
Prepregnancy weight.
Client's Rh factor.: Prenatal blood pressure readings.
The client's blood pressure (BP) (138/88) is below the guideline that indicates mild
preeclampsia. Blood pressure parameters for mild preeclampsia include a reading
of 140/90 taken on two occasions 6 hours apart. However, the client's reading is
significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal
levels, particularly in combination with proteinuria, blurry vision, epigastric pain and
hyperuricemia (uric acid of 6 mg/dl or more). Blood pressure usually remains the
same during the first trimester. Both systolic and diastolic then decrease gradually
up to 20-weeks' gestation. At 20 weeks' gestation, the blood pressure begins to
gradually increase and return to 1st trimester levels at term.
It is important to have early and consistent prenatal care, but this information will not
help in the assessment of this client's condition.
The nurse should compare today's weight to the client's most recently obtained
, N144 Week 5 Case Study - Preeclampsia
Study online at https://quizlet.com/_bkjfdd
previous weight, not to the prepregnancy weight. A weight gain of more than 2
pounds per week is indicative of mild preeclampsia.
While the Rh factor of the mother is important in determining the need for prophy-
lactic Rh immune globulin (RhoGAM) at 28 weeks and after birth, it is not the most
important information at this time. All Rh negative women with negative indirect
Coomb's tests are given RhoGam prophylactically at 28 weeks and then evaluated
immediately after birth to determine if another dose of RhoGam is needed.
5. Section 2
Pathophysiology of Normal Pregnancy vs Preeclampsia
Preeclampsia develops after 20 weeks' gestation in a previously normotensive
woman. Elevated blood pressure is frequently the first sign of preeclampsia.
The client has a headache and blurred vision and also develops protein-
uria. 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 bed rest is often present. Preeclampsia progresses along
a continuum from mild to severe preeclampsia to eclampsia. A client may
present to the labor unit anywhere along that continuum.:
6. Question 3 of 30
What is the pathophysiology responsible for the client's complaint of a pound-
ing headache and the elevated DTRs?
Severe anxiety.
Cerebral edema.
Retinal arteriolar spasms.
Increased perfusion to the brain.: Cerebral edema.
As fluid leaks into the extravascular spaces, organ edema as well as peripheral
edema occurs. This, in conjunction with cortical brain spasms, causes headache,
increased deep tendon reflexes, and clonus.
While the client may be very anxious, this is not the pathophysiology involved.
These spasms are the cause of blurred vision and scotoma that often accompa-
ny worsening of the disease. The decreased perfusion to the brain causes the
headaches.
The hypovolemia that accompanies preeclampsia decreases perfusion to the major
organs.
