Review Intrapartum Management

Pre-eclampsia, Eclampsia > Maternal & Newborn

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Intrapartum Management

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Total Questions : 5

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Question 1:

A nurse is caring for a client with pre-eclampsia who is receiving magnesium sulfate intravenously.

Which of the following assessments is the most important for the nurse to monitor?

A. Blood pressure B. Deep tendon reflexes C. Fetal heart rate D. Urine output

Answer and Explanation

Choice A:

Blood pressure is a major sign of preeclampsia, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Blood pressure may be controlled by other antihypertensive medications.

Choice B:

Deep tendon reflexes are important to monitor because they indicate the level of neuromuscular irritability caused by magnesium sulfate therapy.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.A healthcare provider will give the medication intravenously.If the deep tendon reflexes are absent or diminished, it may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.

Normal ranges:

• Blood pressure: less than 140/90 mm Hg

• Deep tendon reflexes: 2+ (normal) or 3+ (brisk) on a scale of 0 to 4

• Fetal heart rate: 110 to 160 beats per minute

• Urine output: at least 30 mL per hour

Choice C:

Fetal heart rate is important to monitor for fetal well-being, but it is not directly affected by magnesium sulfate therapy.Fetal heart rate may be monitored by nonstress test or biophysical profile.

Choice D:

Urine output is important to monitor for kidney function, but it is not the most important assessment to monitor when receiving magnesium sulfate therapy.Urine output may be measured by urine analysis or 24-hour urine sample.

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Question 2:

A client with eclampsia has a seizure during labor.

Which of the following actions should the nurse take first?

A. Turn the client to the side B. Administer oxygen via face mask C. Give additional magnesium sulfate D. Document the duration and characteristics of the seizure

Answer and Explanation

Choice A:

Turning the client to the side will prevent aspiration and maintain a patent airway, which is the priority intervention for a client who has a seizure.

Choice B:

Oxygen administration alone will not prevent aspiration or ensure a patent airway.Oxygen may be given after turning the client to the side and assessing the respiratory status.

Choice C:

Magnesium sulfate is used to prevent seizures in clients with eclampsia, not to treat them once they occur.Magnesium sulfate may be given after stabilizing the client and checking the serum magnesium level, which should be between 4 to 7 mg/dL (3.3 to 5.8 mEq/L) for therapeutic effect.

Choice D:

Documentation is important but not urgent in this situation.The nurse should document the seizure after providing immediate care and notifying the provider.

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Question 3:

A nurse is preparing to administer hydralazine to a client with pre-eclampsia who has a blood pressure of 170/112 mmHg.

Which of the following parameters should the nurse monitor before and after giving the medication? (Select all that apply.)

A. Heart rate B. Respiratory rate C. Temperature D. Oxygen saturation E. Fetal movement

Answer and Explanation

Choice A:

Hydralazine is a medication that lowers blood pressure by relaxing the blood vessels.It is used to treat hypertension in pre-eclampsia, a condition that causes high blood pressure and proteinuria in pregnant women.Hydralazine can cause side effects such as palpitations, tachycardia, chest pain, and headache.

Therefore, the nurse should monitor the heart rate before and after giving the medication to assess the effectiveness and safety of the treatment.

Choice B:

Respiratory rate is wrong because hydralazine does not affect the respiratory system directly.However, if the blood pressure is too low, it can cause difficulty breathing or shortness of breath.

This is a sign of hypotension or shock and requires immediate medical attention.

Choice C:

Temperature is wrong because hydralazine does not cause fever or affect the body temperature.However, some people may experience a feeling of warmth or flushing after taking hydralazine.

This is a normal reaction and does not indicate a problem.

Choice D:

Oxygen saturation is wrong because hydralazine does not affect the oxygen level in the blood.

However, if the blood pressure is too low, it can cause decreased blood flow to the vital organs, which can lead to hyp ...

Choice E:

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Question 4:

A nurse is reviewing the laboratory results of a client with pre-eclampsia who is scheduled for induction of labor.

Which of the following findings indicates a risk for disseminated intravascular coagulation (DIC)?

A. Platelet count of 150,000/mm3 B. Fibrinogen level of 300 mg/dL C. Prothrombin time of 15 seconds D. D-dimer level of 0.8 mcg/mL

Answer and Explanation

Choice A:

Platelet count of 150,000/mm3 is within the normal range for adults, which is between 150,000 and 450,000 platelets/mcL.Platelet count may decrease in DIC due to excessive clotting and consumption of platelets.

Choice B:

Fibrinogen level of 300 mg/dL is within the normal range for adults, which is between 200 and 400 mg/dL.

Fibrinogen is a protein that helps blood clotting.Fibrinogen level may increase in DIC due to inflammation and tissue injury.

Choice C:

Prothrombin time of 15 seconds is within the normal range for adults, which is between 11 and 13.5 seconds.

Prothrombin time measures how long it takes for blood to clot.Prothrombin time may increase in DIC due to depletion of clotting factors.

Choice D:

D-dimer is a protein fragment that is produced when a blood clot dissolves.A high level of D-dimer indicates a risk for disseminated intravascular coagulation (DIC), a condition in which blood clots form throughout the body and block blood flow to vital organs.

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Question 5:

A nurse is teaching a client with pre-eclampsia about the signs and symptoms of magnesium toxicity.

Which of the following statements by the client indicates a need for further teaching?

A. “I should report any difficulty breathing to my nurse.” B. “I should expect to feel some warmth and flushing when I receive magnesium.” C. “I should notify my nurse if I have blurred vision or a headache.” D. “I should not worry if I do not feel my baby move as much as before.”

Answer and Explanation

Choice A:

Difficulty breathing is a sign of magnesium toxicity and should be reported to the nurse.

Magnesium can depress the respiratory system and cause respiratory failure.

Choice B:

Warmth and flushing are common side effects of magnesium infusion and do not indicate toxicity.

They are caused by the vasodilatory effect of magnesium on the blood vessels.

Choice C:

Blurred vision and headache are signs of severe pre-eclampsia and should be reported to the nurse.

They indicate increased blood pressure and possible cerebral edema.

Choice D:

This statement indicates a need for further teaching because decreased fetal movement is a sign of fetal distress and should be reported to the nurse immediately.

Magnesium toxicity can affect the fetal central nervous system and cause hypotonia and reduced activity.

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Intrapartum Management

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