OLIVIA JONES- SEVERE PREECLAMPSIA

Which of the entries on a patient's medical record are evidence of the diagnosis of severe preeclampsia? (Select all that apply.)

• Oliguria

• Blood pressure 182/116 mmHg

• 3 lb (1.4 kg) weight gain in 1 week

• Epigastric pain

• Negative urine ketones

Which of the following need to be implemented when a patient with severe preeclampsia is admitted to the hospital? (Select all that apply.)

• Television for entertainment

• Bed rest in a left lateral lying position

• Frequent visitors for diversion and support

• Seizure precautions

• Dim lighting

What are the priorities of care if a pregnant woman experiences an eclamptic seizure? (Select all that apply.)

• Administer oxygen

• Protect the patient from injury

• Clear the airway

• Insert a bite block to protect the tongue

• Begin a cesarean birth immediately

Patients with severe preeclampsia are at risk for developing acute pulmonary edema. What can the nurse do to prevent the development of this condition?

• Use the incentive spirometer every 2 hours

• Monitor the patient's SpO2 levels

• Administer oxygen continuously

• Control the rate of administration of intravenous (IV) fluids

Which of the following findings from the nurse's assessment of the patient with severe preeclampsia would indicate central nervous system involvement? (Select all that apply.)

• Absent deep tendon reflexes (DTRs)

• 4+ deep tendon reflexes (DTRs)

• Positive clonus

• Visual changes

• Negative clonus

Ms. Jones's magnesium sulfate infusion is started. How does the nurse assess the effectiveness of the magnesium sulfate treatment?

• Monitor blood pressure

• Monitor urine output

• Monitor deep tendon reflexes (DTRs)

• Monitor uterine contractions

Which of the following need to be implemented when a patient with severe preeclampsia is admitted to the hospital? (Select all that apply.)

• Television for entertainment

• Bed rest in a left lateral lying position

• Frequent visitors for diversion and support

• Seizure precautions

• Dim lighting

Ms. Jones is complaining of nausea and RUQ pain. Which set of labs would the nurse expect the provider to order based on her symptoms?

• BUN, creatinine, uric acid

• Complete blood count (CBC), platelet count, fibrinogen level

• 24-hour urine collection for protein, bile, and creatinine

• Lactate dehydrogenase (LDH), alanine aminotransferase (ALT), aspartate aminotransferase (AST)

A review of Ms. Jones's lab results reveals thrombocytopenia. Based on this information, which of the following nursing actions is important while caring for this patient?

• Have 2 units of packed red blood cells (PRBC) cross-match available in the blood bank

• Apply firm pressure to puncture sites for 2 minutes

• Place an ampule of vitamin K at the bedside

• Obtain an order to administer steroids

After admitting Ms. Jones, the nurse calls the provider. What data would the nurse include in the situation-background-assessment-recommendation (SBAR) communications? (Select all that apply.)

• Clonus 1+

• Mother thinks her daughter is having a heart attack

• Patient is scared

• Coarse crackles in lungs

• Severe headache