The clinic nurse’s patient is 21 weeks pregnant. Her blood pressure is 168/100. Blood pressures in prior visits have all been normal. Her urine sample shows trace protein. What other questions or procedures might you ask/perform to determine if your patient is pre-eclamptic. (Select all that apply)

Do you have any headaches or blurry vision?

I am going to check your reflexes now

Have you been having trouble with urinary incontinence?

Do you have any right upper quadrant pain?

Have you had any nausea or vomiting recently?

Do you feel safe at home?

Answer and Explanation

Correct Answer : A,B,D

A. Do you have any headaches or blurry vision? Headaches and blurry vision are common neurological symptoms of preeclampsia. These occur due to cerebral edema and hypertension-related vascular changes. Persistent headaches or visual disturbances (such as seeing spots or flashing lights) warrant further evaluation.

B. I am going to check your reflexes now. Hyperreflexia (brisk deep tendon reflexes) is a key neurological sign of worsening preeclampsia. Severe hyperreflexia can indicate impending eclampsia and increased seizure risk. Checking for clonus (involuntary rhythmic muscle contractions) is also important.

C. Have you been having trouble with urinary incontinence? Urinary incontinence is not a sign of preeclampsia. However, decreased urine output (oliguria) would be concerning as it may indicate worsening renal impairment, but incontinence itself is unrelated.

D. Do you have any right upper quadrant pain? Right upper quadrant or epigastric pain is a concerning sign of liver involvement in severe preeclampsia or HELLP syndrome. It occurs due to liver swelling and can be a precursor to serious complications such as hepatic rupture.

E. Have you had any nausea or vomiting recently? While nausea and vomiting are common in pregnancy, they are not defining symptoms of preeclampsia unless they are sudden and severe. If present in the third trimester, they may suggest worsening disease, but they are not primary indicators.

F. Do you feel safe at home? Screening for domestic violence is important in pregnancy, but it is not a diagnostic question for preeclampsia. While stress and abuse can impact blood pressure, this question does not help in determining preeclampsia.

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Correct Answer is A

Explanation

A. The patient's blood pressure dropped from 160/120 to 130/90. Hydralazine is an antihypertensive medication used to lower blood pressure in conditions such as eclampsia. A reduction in blood pressure indicates that the medication is achieving its intended effect of controlling hypertension, reducing the risk of complications like stroke or organ damage.

B. The patient states that her headache is gone. While headaches are a symptom of severe hypertension, their resolution does not directly confirm the effectiveness of hydralazine. Other factors, such as pain relief or improved postpartum recovery, could contribute to headache relief.

C. The patient's postoperative weight has dropped from 155 to 144 pounds. Postpartum weight loss is expected due to fluid shifts and loss of pregnancy-related fluids, but it is not a direct measure of hydralazine’s effectiveness. The medication does not act as a diuretic or weight-loss agent.

D. The patient has had no seizures since delivery. While hydralazine helps lower blood pressure, preventing seizures in eclamptic patients is primarily managed with magnesium sulfate, not hydralazine. The absence of seizures is important but does not indicate the specific effectiveness of this antihypertensive medication.

A. Quantity of vaginal bleeding B. Presence of abdominal pain C. Leopold's maneuver results. D. Maternal blood pressure

Correct Answer is B

Explanation

A. Quantity of vaginal bleeding. While both placenta previa and abruptio placentae can cause vaginal bleeding, the amount alone does not differentiate between the two conditions. Placenta previa typically causes painless, bright red bleeding, whereas abruptio placentae often presents with concealed or variable bleeding, making quantity an unreliable distinguishing factor.

B. Presence of abdominal pain. Abdominal pain is a key differentiating factor. Placenta previa is characterized by painless vaginal bleeding, while abruptio placentae causes sudden, severe abdominal pain due to placental detachment and uterine muscle irritation. This makes the presence or absence of pain an important assessment finding.

C. Leopold's maneuver results. While Leopold’s maneuvers help determine fetal position and presentation, they do not provide definitive information about the location of the placenta or differentiate between placenta previa and abruptio placentae. Ultrasound is a more reliable diagnostic tool for this purpose.

D. Maternal blood pressure. Although abruptio placentae can lead to hypovolemic shock and blood pressure changes due to hemorrhage, maternal blood pressure alone is not a primary diagnostic criterion for differentiating between the two conditions. Other clinical findings such as pain and ultrasound results are more useful for diagnosis.

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Naxlex Comprehensive Predictor Exams

A patient is 3 days post c-section delivery for eclampsia. The client is receiving hydralazine (Apresoline). Which of the following would indicate that the medication is effective?

Correct Answer is A

Explanation

A 29-week gravid patient is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following?

Correct Answer is B

Explanation

A woman, G4P0210, and 12 weeks' gestation has been admitted to labor and delivery for a cerclage procedure. Which of the following long-term goals for this patient would we anticipate by doing this procedure?

Preconception counseling is critical to the outcome of a pregnancy for a patient with diabetes because poor glycemic control before and during early pregnancy is associated with:

To assist with an induction of labor which of these medications can be used? Select all that apply

The nurse is assessing a patient who has severe preeclampsia. The assessment finding that should be reported to the physician is:

The nurse is preparing for the admission of a 30 weeks' gestation patient experiencing vaginal bleeding with a suspected diagnosis of placenta previa. In anticipating the patient's needs, which of the following would be most appropriate for the nurse to include? Select all that apply.

A pregnant woman is just admitted to the emergency room after a head on auto accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which complication(s) of pregnancy? (Select all that apply)

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. Which finding is most indicative that preterm labor is occurring?

A nurse is monitoring the labor of a patient who is receiving IV oxytocin (Pitocin) at 6 ml/hr. Which of the following clinical signs would lead the nurse to stop the infusion?