Instructor Avatar Help Info
Students can click on the Instructor Avatar for more information to help them with the case. Click on
avatar and a window appears with the following options:
 Preeclampsia pathophysiology
 Common lab tests
 Preeclampsia dangers

Preeclampsia pathophysiology
Preeclampsia progresses along a continuum from mild to severe preeclampsia, HELLP syndrome, or
eclampsia. There is no definitive cause of preeclampsia, but the pathophysiology is distinct.
 Preeclampsia develops after 20 weeks gestation in a previously normotensive woman.
 Elevated blood pressure is frequently the first sign of preeclampsia.
 The client also develops proteinuria.
 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 bedrest is often present
Common lab tests
Common lab tests done to diagnose pregnancy-induced hypertension
1. CBC
2. Urinalysis
3. BMP (basic metabolic panel, including BUN/Cre)
Preeclampsia dangers
The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm. Function in organs
such as the placenta, liver, brain, and kidneys can be depressed as much as 40 to 60%. As fluid
shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase
in hematocrit is seen. The edema of preeclampsia is generalized. Virtually all organ systems are
affected by this disease, and the mother and fetus suffer increasing risk as the disease progresses.
Preeclampsia is associated with risks of placental abruption, acute renal failure, cerebrovascular
and cardiovascular complications, disseminated intravascular coagulation, and maternal death.
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Initial History and Assessment
At 09:26 a.m. Jennie is brought to the Labor and Delivery triage area by her sister.
Nurse must select the next appropriate action:
a. introduction
b. provide privacy
c. perform physical assessment
d. place an identification bracelet on the client
Nursing student should select to perform introduction first. If not, the student is redirected. Feedback
for each incorrect response would be: What action should be performed FIRST?
Nurse says
Patient says
Sister says
Good morning, I’m Kelsey Hogan
and I’ll be your student nurse for
the day. Tell me your name, date
of birth, and what brought you
here this morning.
I feel lousy. I’ve had this
unbelievable headache for the
past 2 days. I can’t seem to get rid
of it even with Tylenol. On top of
that my hands and face are huge
and I can’t seem to get rid of this
heartburn.
"I felt like that when I had
toxemia during my
pregnancy. She’s been dizzy
sometimes, too."
Avatar provides: Family history
Both maternal grandparents died from natural causes. From the paternal side, the grandmother died
from complications of hypertension and the father died from pneumonia. Her mother is not
experiencing any health problems but Jennie’s father has hypertension and asthma. Jennie was
without any significant health history.
Admission assessment by the nurse: Jennie is at 32 weeks gestation per ultrasound. Today's weight is 182
pounds with a pre-pregnancy weight of 145. Her most recent OB visit revealed TPR-BP: 99.1° F (oral),
76, 24, 138/88, pain 2/10 (epigastric area).
Nurse says
Nurse: I’m sorry you’re not
feeling well today. I’ll get your
vital signs and perform a physical
assessment so we can try to find
out what’s causing your
discomfort.
Patient says
Okay.
Sister says
Nurse performs triage assessment.
[as nurse clicks on the different areas, the information will appear in a drop down window that looks
like a computer screen]
Directions:
Check time on clock.
Check temperature [student clicks on thermometer on machine]
Check pulse [student clicks on wrist]
Check respiration [student clicks on chest—glows]
Check blood pressure [student clicks on blood pressure cuff]
Results on computer screen:
Time: 1000
Temp: 99.2
Pulse: 78
Resp: 20
BP: 155/90
Nurse says
Patient says
On a scale of 0-10, with 0 being
no pain and 10, the worst pain
you’ve ever had, how would you
rate your pain level today?
Tell me where your pain is
located. When did it start? How
would you describe the pain?
Has anything helped relieve the
pain?
Okay. Let me take a closer look.
I’d give it an 8.
Sister says
I have a terrible pounding
headache, all over but mostly
around my temples. It started last
night and like I said the Tylenol
just isn’t helping.
I’ve been trying to get her to
eat or at least drink something
but she just wanted to try to
sleep it off. The pain just got
worse and then she started
getting dizzy so I told her she’d
better come in.
Directions on Screen: [as nurse clicks on the different areas, the information will appear in a drop down
window that looks like a computer screen]
Check her alertness [student clicks on head—headache info appears]
Check her eyes [student clicks on eyes—pupil info appears]
Check her nose [student clicks on nose—mucous info appears]
Check her throat [student clicks on neck—patient turns head to the left-Listen to her respirations [student clicks on stethoscope and moves to the chest area—resp. & C/V info
appears—note: hears sounds]
Check her capillary refill [student clicks on index finger right hand—patient’s finger turns white and
back to pink—2 sec.—CRT info appears
Check bowel sounds: [student moves stethoscope down to abdomen—note: hears sounds—Abd. Info
appears
Begin fetal monitoring: [student clicks on fetal monitor and moves straps to patient’s abdomen—straps
slide into place around/under patient
Info that appears:
Alert, oriented x3, complains of pounding headache and occasional dizziness
Eyes with PERRLA, pupils 3mm and with brisk response.
Nasal and oral mucosa pink and slightly dry oral mucousa.
Throat supple and without masses
Resp: breath sounds clear to auscultation bilaterally-anterior, posterior, lateral.
C/V: Heart sounds with regular rate and rhythm, pulses 2+ and equal bilaterally
CRT less than 3 seconds, skin pink
Abd: bowel sounds normoactive, without notable tenderness, pain. Rotunded, soft.
EXT: moves all extremities freely and easily, DTR: Deep tendon reflexes (DTRs) are 3+ biceps and triceps
and 4+ patellar with 1 beat of ankle clonus.
Nurse says
Patient says
Sister says
No
Can you point your feet toward
your head? Do you feel any pain?
“Homan’s sign negative” appears in a thought bubble for the nurse.
As feet are returned to normal resting position, Zoom in on calf. The nurse scrolls over the calf and
notes while the nurse clicks on hand demonstrating 4+ pitting edema.
Jennie’s blood pressure was at 155/90 at 10a.m.; 163/100 at 11 a.m. While normal blood pressure is
below 120/80, blood pressure between 120/80 and 139/89 is called “pre-hypertension,” and a blood
pressure of 140/90 or above is considered high.
Jennie’s hypertension is probably related to:
a. preeclampsia
b. chronic hypertension
c. gestational hypertension
d. renal disease
A Feedback. Your conclusion that Jennie is in jeopardy of developing a hypertensive disorder was
based on which risk factors?
a. Weight, temperature, proteinuria, edema
b. Increased blood pressure, edema, proteinuria
c. Increased blood pressure, respiration, reflexes
Click CONTINUE to return to patient’s room.
B Feedback. Chronic hypertension in pregnancy is defined as a) hypertension that precedes pregnancy, b)
hypertension that occurs in pregnancy prior to 20 weeks of gestation, or c) hypertension that persists beyond
the sixth postpartum week.
Click CONTINUE to return to patient’s room.
C Feedback. Gestational hypertension is defined as hypertension induced by pregnancy beginning after 20
weeks of gestation and resolving by the sixth postpartum week. There would be no evidence of end-organ
manifestation such as proteinuria.
Click CONTINUE to return to patient’s room.
D Feedback. In renal disease, any rise in GFR depends on an elevation in glomerular pressure, which can
increase proteinuria and worsen the underlying disease. Hypertension becomes more severe during pregnancy
in most women with chronic renal disease, and proteinuria increases in approximately 20% of patients.
Click CONTINUE to return to patient’s room.
Pop-up question
What is the pathophysiology responsible for Jennie's complaint of a pounding headache and the
elevated DTRs?
a. XXXX
b. XXXX
c. XXXX
Correct answer turns greens and check mark over the letter. Incorrect answers turn red and X mark
over the letter. Question fades when gets correct answer.
Nurse says
a. XXXX
b. XXXX
c. XXXX
Patient says
Sister says
Sister: I’m really worried about
Jennie’s face and hands. I’ve
never seen them so puffy. Can
you prescribe some of “those
water pills” to help?
A Feedback:
B Feedback:
C Feedback:
What is the next step in treatment?
Apply Fetal Monitor (button option) time?
Results: baseline fetal heart rate of 125-130 beats per minute (bpm), absent variability, positive for
accelerations, no decelerations, and no contractions.
Perform vaginal exam (button option) time?
Results: cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
Pull Down Menu (doctor’s orders)
At 1139 the nurse calls to report to the healthcare provider, who prescribes the following:
1. admit to labor and delivery
2. bed rest with bathroom privileges (BRP)
3. IV D5LR at 125 ml/hr, CBC with platelets
4. clotting studies
5. liver enzymes
6. chemistry panel
7. 24-hour urine collection for protein and uric acid
8. ice chips only by mouth
9. nonstress test
10. hourly vital signs
11. DTRs
While awaiting the lab results, which nursing intervention has the highest priority?
a. XXXX
b. XXXX
c. XXXX
HELLP Syndrome
At 1400, physical assessment and labs reveal the following:
The client is still complaining of a headache but the epigastric pain has slightly decreased.
While resting in a left lateral position, the vital signs are BP 146/94, P 75, R 18.
Hyperreflexia continues with one beat of clonus.
The baseline fetal heart rate is 140 with average long-term variability and no decelerations. Since
completion of a reactive nonstress test, no further accelerations have occurred.
Lab results
hemoglobin - 13.1 g/dl, hematocrit - 40.5 g/dl, platelets - 120,000 mm3, aspartate aminotransferase
(AST) - slightly elevated, alanine aminotransferase (ALT) - normal for pregnancy, 0 burr cells on slide,
clotting studies normal for pregnancy.
The healthcare provider diagnoses Jennie with preeclampsia rather than HELLP syndrome, a variant of
severe preeclampsia.
Evaluation
The 1500 assessment
Jennie reports that her headache has decreased slightly, but the epigastric pain has increased.
Complaints of scotoma began about 5 minutes ago.
Reflexes are 4+ biceps and patellar and 3+ triceps with 3 beats of ankle clonus.
Vital signs are: T 99° F, P 80, R 19, BP 144/96.
The most recent blood magnesium level is 2 gm/dl. Intake since admission (@0600) is 150 ml and
output is 300 ml. The healthcare provider increases the magnesium sulfate prescription to 2 gm/hr.
Fetal monitor tracing reveals a baseline fetal heart rate in the 120s, minimal long-term variability, no
accelerations, and no decelerations.
Uterine contractions are occurring every 4 to 5 minutes and they are moderate quality upon palpation.
Cervical exam indicates the cervix is now 3 cm dilated and 80% effaced, with the presenting part
(cephalic) at -1 station. Jennie reports mild discomfort with contractions but does not want anything
for pain at this time.
Jennie's partner and sister are at the bedside helping her use relaxation breathing through each
contraction. Jennie is in the right lateral position with the head of the bed slightly elevated.
Jennie asks why the magnesium sulfate was increased.
What explanation should the nurse provide?
a. XXXX
b. XXXX
c. XXXX
When the nurse evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate longterm variability.
Case Outcome
By 36-hours postpartum Jennie is diuresing and has decreased edema.