A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.
Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?
Blood pressure of 150/90 mm Hg
Urine protein of 2+
Epigastric pain
Facial edema
The Correct Answer is C
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia. Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
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Correct Answer is A
Explanation
The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.
Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.
Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.
Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.
Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.
Correct Answer is A
Explanation
Stop the magnesium sulfate infusion.
The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.
Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.
The nurse should stop the infusion and monitor the client’s vital signs and neurological status.
Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.
The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.
Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.
It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.
Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.
The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.
Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.
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