NRSG 2500 exam 1 Questions With Complete Solutions
A pregnant woman has been admitted to the hospital due to
preeclampsia with severe features. Which measure will be
important for the nurse to include in the care plan?
Institute NPO status.
Admit the client to the middle of ICU where she can be
constantly monitored.
Institute and maintain seizure precautions.
Plan for immediate induction of labor.
Institute and maintain seizure precautions.
A woman with severe preeclampsia is receiving magnesium
sulfate. The woman's serum magnesium level is 9.0 mEq/L.
Which finding would the nurse most likely note?
serum magnesium level of 6.5 mEq/L
elevated liver enzymes
seizures
diminished reflexes
diminished reflexes
HIP
gestational hypertension
,preeclampsia
abnormal condition associated with pregnancy, marked by high
blood pressure, proteinuria (2+), edema, and headache
treatment: manage blood pressure, turn on left side, encourage
rest
risk factors: previous history of preeclampsia, history of high
blood pressure prior to pregnancy, immediate family history of
preeclampsia, history of obesity, carrying more than one baby,
history of diabetes, lupus, or RA
signs preeclampsia is becoming severe preeclampsia: increasing
edema in hands and face, worsening headache, epigastric pain,
visual disturbances, decreasing urinary output, nausea/vomiting,
bleeding gums (low platelets), disorientation, generalized
complaints of not feeling well
eclampsia
A more serious form of preeclampsia that is characterized by
convulsions and sometimes coma.
>/= 3+ proteinuria
increased blood pressure causes swelling in the brain which
leads to seizures and decrease blood flow to the fetus
treatment: prepare for emergency delivery, administer
magnesium sulfate to control seizures, administer blood pressure
medications, initiate seizure precautions, lower lighting and
other environmental stimuli, monitor vital signs, deep tendon
, reflexes, and check for clonus (muscle spasm when flexing the
foot), check lab work (CBC, CMP, PT, PTT, Magnesium (for
magnesium sulfate medication)
fetal distress
fetus has an abnormal heart rate or rhythm
HR below 110 or above 160, shows decreased or no variability,
and is hyperactive or no activity
nursing care for fetal distress
change maternal position to left side (increases uterine blood
flow), discontinue oxytocin, give 8-10 L of oxygen, increase IV
rate, amnioinfusion (expand uterus and releives cord
compression), assist with emergency C-section
Signs and symptoms of MgSO4 toxicity
depression or abcense of deep tendon reflexes
oliguria
confusion or change in LOC
respiratory depression
circulatory collaps
respiratory paralysis
preterm labor
cervical effacement and dilation and uterine contractions < 37
weeks of pregnancy
one of the common obstetric complications
treatment: administer corticosteroids (betamethasone) to help in
developing fetus' lungs and produce surfactant
A pregnant woman has been admitted to the hospital due to
preeclampsia with severe features. Which measure will be
important for the nurse to include in the care plan?
Institute NPO status.
Admit the client to the middle of ICU where she can be
constantly monitored.
Institute and maintain seizure precautions.
Plan for immediate induction of labor.
Institute and maintain seizure precautions.
A woman with severe preeclampsia is receiving magnesium
sulfate. The woman's serum magnesium level is 9.0 mEq/L.
Which finding would the nurse most likely note?
serum magnesium level of 6.5 mEq/L
elevated liver enzymes
seizures
diminished reflexes
diminished reflexes
HIP
gestational hypertension
,preeclampsia
abnormal condition associated with pregnancy, marked by high
blood pressure, proteinuria (2+), edema, and headache
treatment: manage blood pressure, turn on left side, encourage
rest
risk factors: previous history of preeclampsia, history of high
blood pressure prior to pregnancy, immediate family history of
preeclampsia, history of obesity, carrying more than one baby,
history of diabetes, lupus, or RA
signs preeclampsia is becoming severe preeclampsia: increasing
edema in hands and face, worsening headache, epigastric pain,
visual disturbances, decreasing urinary output, nausea/vomiting,
bleeding gums (low platelets), disorientation, generalized
complaints of not feeling well
eclampsia
A more serious form of preeclampsia that is characterized by
convulsions and sometimes coma.
>/= 3+ proteinuria
increased blood pressure causes swelling in the brain which
leads to seizures and decrease blood flow to the fetus
treatment: prepare for emergency delivery, administer
magnesium sulfate to control seizures, administer blood pressure
medications, initiate seizure precautions, lower lighting and
other environmental stimuli, monitor vital signs, deep tendon
, reflexes, and check for clonus (muscle spasm when flexing the
foot), check lab work (CBC, CMP, PT, PTT, Magnesium (for
magnesium sulfate medication)
fetal distress
fetus has an abnormal heart rate or rhythm
HR below 110 or above 160, shows decreased or no variability,
and is hyperactive or no activity
nursing care for fetal distress
change maternal position to left side (increases uterine blood
flow), discontinue oxytocin, give 8-10 L of oxygen, increase IV
rate, amnioinfusion (expand uterus and releives cord
compression), assist with emergency C-section
Signs and symptoms of MgSO4 toxicity
depression or abcense of deep tendon reflexes
oliguria
confusion or change in LOC
respiratory depression
circulatory collaps
respiratory paralysis
preterm labor
cervical effacement and dilation and uterine contractions < 37
weeks of pregnancy
one of the common obstetric complications
treatment: administer corticosteroids (betamethasone) to help in
developing fetus' lungs and produce surfactant
