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Care of adults and older adults (University of St. Thomas (Texas))
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Chapter 27: Hypertensive Disorders
Lowdermilk: Maternity & Women’s Health Care, 12th Edition
MULTIPLE CHOICE
1. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is
of greatest concern to the nurse?
a. Blood pressure (BP) increase to 138/86 mm Hg
b. Weight gain of 0.5 kg during the past 2 weeks
c. Dipstick value of 3+ for protein in her urine
d. Pitting pedal edema at the end of the day
ANS: C
Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A
dipstick value of 3+ alerts the nurse that additional testing or assessment should be
performed. A 24-hour urine collection is preferred over dipstick testing attributable to
accuracy. Generally, hypertension is defined as a BP of 140/90 mm Hg or an increase in
systolic pressure of 30 mm Hg or diastolic pressure of 15 mm Hg. Preeclampsia may be
demonstrated as a rapid weight gain of more than 2 kg in 1 week. Edema occurs in many
normal pregnancies, as well as in women with preeclampsia. Therefore, the presence of
edema is no longer considered diagnostic of preeclampsia.
PTS: 1
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
NURwith
GTB.COMis going to be induced. Before initiating
2. The labor of a pregnant woman
SINpreeclampsia
the oxytocin infusion, the nurse reviews the woman’s latest laboratory test findings, which
reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level,
and a falling hematocrit. The laboratory results are indicative of which condition?
a. Eclampsia
b. Disseminated intravascular coagulation (DIC) syndrome
c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP)
syndrome
d. Idiopathic thrombocytopenia
ANS: C
HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that
involves hepatic dysfunction characterized by hemolysis (H), elevated liver (EL) enzymes,
and low platelets (LP). Eclampsia is determined by the presence of seizures. DIC is a
potential complication associated with HELLP syndrome. Idiopathic thrombocytopenia is
the presence of low platelets of unknown cause and is not associated with preeclampsia.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
3. A woman with preeclampsia has a seizure. What is the nurse’s highest priority during a
seizure?
a. To insert an oral airway
b. To suction the mouth to prevent aspiration
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c. To administer oxygen by mask
d. To stay with the client and call for help
ANS: D
If a client becomes eclamptic, then the nurse should stay with the client and call for help.
Nursing actions during a convulsion are directed toward ensuring a patent airway and client
safety. Insertion of an oral airway during seizure activity is no longer the standard of care.
The nurse should attempt to keep the airway patent by turning the client’s head to the side to
prevent aspiration. Once the seizure has ended, it may be necessary to suction the client’s
mouth. Oxygen is administered after the convulsion has ended.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
4. A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe
preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs:
temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute,
BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client
complains, <I’m so thirsty and warm.= What is the nurse’s immediate action?
a. To call for an immediate magnesium sulfate level
b. To administer oxygen
c. To discontinue the magnesium sulfate infusion
d. To prepare to administer hydralazine
ANS: C
Regardless of the magnesium level, the client is displaying the clinical signs and symptoms
of magnesium toxicity. The first action by the nurse should be to discontinue the infusion of
NURcalcium
B.COM the antidote for magnesium, may be
SINGTgluconate,
magnesium sulfate. In addition,
administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension
in severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than
160 mm Hg or a diastolic BP higher than 110 mm Hg.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
5. A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor
and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2
minutes, dark red vaginal bleeding, and a tense, painful abdomen. Which clinical change
does the nurse anticipate?
a. Eclamptic seizure
b. Rupture of the uterus
c. Placenta previa
d. Placental abruption
ANS: D
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Uterine tenderness in the presence of increasing tone may be the earliest sign of placental
abruption. Women with preeclampsia are at increased risk for an abruption attributable to
decreased placental perfusion. Eclamptic seizures are evidenced by the presence of
generalized tonic-clonic convulsions. Uterine rupture exhibits hypotonic uterine activity,
signs of hypovolemia, and, in many cases, the absence of pain. Placenta previa exhibits
bright red, painless vaginal bleeding.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
6. A woman with worsening preeclampsia is admitted to the hospital’s labor and birth unit.
The physician explains the plan of care for severe preeclampsia, including the induction of
labor, to the woman and her partner. Which statement by the partner leads the nurse to
believe that the couple needs further information?
a. <I will help her use the breathing techniques that we learned in our childbirth
classes.=
b. <I will give her ice chips to eat during labor.=
c. <Since we will be here for a while, I’ll ask my mother, to bring our toddler to
visit.=
d. <I will stay with her during her labor, just as we planned.=
ANS: C
Arranging a visit with their toddler indicates that the partner does not understand the
importance of the quiet, subdued environment that is needed to prevent this condition from
worsening. Implementing breathing techniques is indicative of adequate knowledge related
to pain management during labor. Administering ice chips indicates an understanding of
nutritional needs during labor.
his O
partner
NURStaying
M during labor demonstrates the
SINGwith
TB.C
husband’s support and is appropriate.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
7. The client is being induced in response to worsening preeclampsia. She is also receiving
magnesium sulfate. It appears that her labor has not become active, despite several hours of
oxytocin administration. She asks the nurse, <Why is this taking so long?= What is the
nurse’s most appropriate response?
a. <Since the magnesium is competing with the oxytocin, your labor is slowed.=
b. <I don’t know why it is taking so long.=
c. <The length of labor varies for different women.=
d. <Your baby is just being stubborn.=
ANS: A
Because magnesium sulfate is a tocolytic agent, its use may increase the duration of labor.
The amount of oxytocin needed to stimulate labor may be more than that needed for the
woman who is not receiving magnesium sulfate. The nurse should explain to the client the
effects of magnesium sulfate on the duration of labor. Although the length of labor varies
for different women, the most likely reason this woman’s labor is protracted is the tocolytic
effects of magnesium sulfate. The behavior of the fetus has no bearing on the length of
labor.
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PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
8. What nursing diagnosis is the most appropriate for a woman experiencing severe
preeclampsia?
a. Potential for injury to mother and fetus, related to central nervous system (CNS)
irritability
b. Potential for reduced gas exchange
c. Potential for inadequate fluid volume, related to increased sodium retention
secondary to the administration of magnesium sulfate
d. Potential for increased cardiac output, related to the use of antihypertensive drugs
ANS: A
Potential for injury is the most appropriate nursing diagnosis for this client scenario. Gas
exchange is more likely to become reduced, attributable to pulmonary edema. A potential
for increased, not decreased, fluid volume, related to increased sodium retention, and a
potential for decreased, not increased, cardiac output, related to the use of antihypertensive
drugs, also is increased.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
9. Which statement best describes chronic hypertension?
a. Chronic hypertension is defined as hypertension that begins during pregnancy and
lasts for the duration of the pregnancy.
b. Chronic hypertension isNconsidered
URSINGsevere
TB.Cwhen
OM the systolic BP is higher than 140
mm Hg or the diastolic BP is higher than 90 mm Hg.
c. Chronic hypertension is general hypertension plus proteinuria.
d. Chronic hypertension can occur independently of or simultaneously with
preeclampsia.
ANS: D
Women with chronic hypertension may develop superimposed preeclampsia, which
increases the morbidity for both the mother and the fetus. Chronic hypertension is present
before pregnancy or diagnosed before the 20 weeks of gestation and persists longer than 6
weeks postpartum. Chronic hypertension becomes severe with a diastolic BP of 110 mm Hg
or higher. Proteinuria is an excessive concentration of protein in the urine and is a
complication of hypertension, not a defining characteristic.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis | Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
10. Which intervention is most important when planning care for a client with severe gestational
hypertension?
a. Induction of labor is likely, as near term as possible.
b. If at home, the woman should be confined to her bed, even with mild gestational
hypertension.
c. Special diet low in protein and salt should be initiated immediately.
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d. Vaginal birth is still an option, even in severe cases.
ANS: A
By 34 weeks of gestation, the risk of continuing the pregnancy may be considered greater
than the risks of a preterm birth. Strict bed rest is controversial for mild cases; some women
in the hospital are even allowed to move around. Diet and fluid recommendations are
essentially the same as for healthy pregnant women, although some authorities have
suggested a diet high in protein. Women with severe gestational hypertension should expect
a cesarean delivery.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
11. Which client exhibits the greatest number of risk factors associated with the development of
preeclampsia?
a. 30-year-old obese Caucasian with her third pregnancy
b. 41-year-old Caucasian primigravida
c. 19-year-old African American who is pregnant with twins
d. 25-year-old Asian American whose pregnancy is the result of donor insemination
ANS: C
Three risk factors are present in the 19-year-old African-American client. She has
African-American ethnicity, is at the young end of the age distribution, and has a multiple
pregnancy. In planning care for this client, the nurse must frequently monitor her BP and
teach her to recognize the early warning signs of preeclampsia. The 30-year-old obese
Caucasian client has only has one known risk factor: obesity. Age distribution appears to be
NURS
I G B.COM
U-shaped, with women younger
thanN20Tyears of
age and women older than 40 years of age
being at greatest risk. Preeclampsia continues to be more frequently observed in
primigravidas; this client is a multigravida woman. Two risk factors are present for the
41-year-old Caucasian primigravida client. Her age and status as a primigravida place her at
increased risk for preeclampsia. Caucasian women are at a lower risk than are
African-American women. The 25-year-old Asian-American client exhibits only one risk
factor. Pregnancies that result from donor insemination, oocyte donation, and embryo
donation are at an increased risk of developing preeclampsia.
PTS: 1
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
12. Which neonatal complications are associated with hypertension in the mother?
a. Intrauterine growth restriction (IUGR) and prematurity
b. Seizures and cerebral hemorrhage
c. Hepatic or renal dysfunction
d. Placental abruption and DIC
ANS: A
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Neonatal complications are related to placental insufficiency and include IUGR,
prematurity, and necrotizing enterocolitis. Seizures and cerebral hemorrhage are maternal
complications. Hepatic and renal dysfunction are maternal complications of hypertensive
disorders in pregnancy. Placental abruption and DIC are conditions related to maternal
morbidity and mortality.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
13. The nurse has evaluated a client with preeclampsia by assessing deep tendon reflexes
(DTRs). The result is a grade of 3+. Which DTR response most accurately describes this
score?
a. Sluggish or diminished
b. Brisk, hyperactive, with intermittent or transient clonus
c. Active or expected response
d. More brisk than expected, slightly hyperactive
ANS: D
DTRs reflect the balance between the cerebral cortex and the spinal cord. They are
evaluated at baseline and to detect changes. A slightly hyperactive and brisk response
indicates a grade 3+ response.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
14. A woman experiencing severe preeclampsia has been receiving magnesium sulfate by
intravenous infusion for 8 hours.
assesses
NURSThe
INnurse
GTB.C
OM the client and documents the following
findings: temperature of 37.1° C, pulse rate of 96 beats per minute, respiratory rate of 24
breaths per minute, BP of 155/112 mm Hg, 3+ DTRs, and no ankle clonus. The nurse calls
the provider with an update. The nurse should anticipate an order for which medication?
a. Hydralazine
b. Magnesium sulfate bolus
c. Diazepam
d. Calcium gluconate
ANS: A
Hydralazine is an antihypertensive medication commonly used to treat hypertension in
severe preeclampsia. Typically, it is administered for a systolic BP higher than 160 mm Hg
or a diastolic BP higher than 110 mm Hg. An additional bolus of magnesium sulfate may be
ordered for increasing signs of CNS irritability related to severe preeclampsia (e.g., clonus)
or if eclampsia develops. Diazepam is sometimes used to stop or shorten eclamptic seizures.
Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not
currently displaying any signs or symptoms of magnesium toxicity.
PTS: 1
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
15. The client being cared for has severe preeclampsia and is receiving a magnesium sulfate
infusion. Which new finding would give the nurse cause for concern?
a. Sleepy, sedated affect
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b. Respiratory rate of 10 breaths per minute
c. Deep tendon reflexes (DTRs) of 2+
d. Absent ankle clonus
ANS: B
A respiratory rate of 10 breaths per minute indicates the client is experiencing respiratory
depression from magnesium toxicity. Because magnesium sulfate is a CNS depressant, the
client will most likely become sedated when the infusion is initiated. DTRs of 2+ and absent
ankle clonus are normal findings.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
16. What is the most common medical complication of pregnancy?
a. Hypertension
b. Hyperemesis gravidarum
c. Hemorrhagic complications
d. Infections
ANS: A
Preeclampsia and eclampsia are two noted deadly forms of hypertension. A large percentage
of pregnant women will have nausea and vomiting, but a relatively few will have the severe
form called hyperemesis gravidarum. Hemorrhagic complications are the second most
common medical complication of pregnancy; hypertension is the most common. Infection is
a risk factor for preeclampsia.
PTS: 1
DIF: Cognitive Level: Remember
NURSINGTB.C
OM Client Needs: Physiologic Integrity
TOP: Nursing Process: Assessment
MSC:
17. Which statement most accurately describes the HELLP syndrome?
a. Mild form of preeclampsia
b. Diagnosed by a nurse alert to its symptoms
c. Characterized by hemolysis, elevated liver enzymes, and low platelets
d. Associated with preterm labor but not perinatal mortality
ANS: C
The acronym HELLP stands for hemolysis (H), elevated liver (EL) enzymes, and low
platelets (LP). The HELLP syndrome is a variant of severe preeclampsia and is difficult to
identify because the symptoms are not often obvious. The HELLP syndrome must be
diagnosed in the laboratory. Preterm labor is greatly increased; therefore, so is perinatal
mortality.
PTS: 1
DIF: Cognitive Level: Understand
TOP: Nursing Process: Diagnosis | Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. Which adverse prenatal outcomes are associated with the HELLP syndrome? (Select all that
apply.)
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a.
b.
c.
d.
e.
Placental abruption
Placenta previa
Renal failure
Cirrhosis
Maternal and fetal death
ANS: A, C, E
The HELLP syndrome is associated with an increased risk for adverse perinatal outcomes,
including placental abruption, acute renal failure, subcapsular hepatic hematoma, hepatic
rupture, recurrent preeclampsia, preterm birth, and fetal and maternal death. The HELLP
syndrome is associated with an increased risk for placental abruption, not placenta previa. It
is also associated with an increased risk for hepatic hematoma, not cirrhosis.
PTS: 1
DIF: Cognitive Level: Analyze
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
2. One of the most important components of the physical assessment of the pregnant client is
the determination of blood pressure (BP). Which techniques are important in obtaining
accurate BP readings? (Select all that apply.)
a. The client should be seated.
b. The client’s arm should be placed at the level of the heart.
c. An electronic BP device should be used.
d. The cuff should cover a minimum of 60% of the upper arm.
e. The same arm should be used for every reading.
ANS: A, B, E
BP readings are easily affected by maternal position. Ideally, the client should be seated. An
NURSrecumbent
INGTB.C
M
alternative position is left lateral
withOthe arm at the level of the heart. The arm
should always be held in a horizontal position at approximately the level of the heart. The
same arm should be used at every visit. The manual sphygmomanometer is the most
accurate device. If manual and electronic devices are used in the care setting, then the nurse
must use caution when interpreting the readings. A proper size cuff should cover at least
80% of the upper arm or be approximately 1.5 times the length of the upper arm.
PTS: 1
DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
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