Practice Question
Patient's data.
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Rationale:
Most Likely Current Condition:
Preeclampsia with severe features
🎯 Olivia presents with severe-range BP (164/112 mmHg), thrombocytopenia (platelets 120,000/mm³), elevated AST (76 U/L), neurologic symptoms (headache, blurry vision), and 3+ reflexes with clonus.
🎯 These findings meet criteria for preeclampsia with severe features, not just mild preeclampsia or gestational hypertension.
🎯 Severe features signal multi-organ involvement, increasing risk for eclampsia, stroke, and fetal compromise.
🎯 Prompt treatment is necessary to stabilize the mother and determine timing of delivery.
🎯 Her condition warrants inpatient management, magnesium sulfate, and close monitoring.
Priority Nursing Actions:
Implement seizure precautions
🎯 Neurologic symptoms and hyperreflexia place Olivia at high risk for seizures.
🎯 Standard seizure precautions include padded side rails, suction setup, reduced stimulation, and emergency meds at bedside.
🎯 These precautions aim to reduce injury if seizure occurs before magnesium takes full effect.
🎯 This is a priority safety intervention for clients with severe preeclampsia.
🎯 Continuous assessment for changes in consciousness is also important.
Start magnesium sulfate infusion as ordered
🎯 Magnesium sulfate is the drug of choice to prevent eclampsia in patients with severe features.
🎯 The ordered 4 g IV bolus and 2 g/hr maintenance dose is standard protocol.
🎯 It works by suppressing CNS irritability, reducing seizure risk.
🎯 Must monitor for signs of toxicity: loss of reflexes, respiratory depression, and decreased urine output.
🎯 Baseline reflexes and continuous fetal/maternal monitoring are essential during infusion.
Notify provider of abnormal labs (platelets, AST)
🎯 A platelet count of 120,000/mm³ and elevated AST (76 U/L) indicate hematologic and hepatic involvement.
🎯 These lab abnormalities are signs of disease progression and may signal early HELLP syndrome.
🎯 The provider must be updated for possible escalation of care or early delivery planning.
🎯 Accurate and timely reporting improves clinical decision-making and maternal-fetal outcomes.
🎯Repeating labs may be necessary to trend disease severity.
Key Parameters to Monitor:
Respiratory rate
🎯 Monitoring RR is essential because magnesium sulfate can depress respiration.
🎯 A respiratory rate <12/min is a red flag for magnesium toxicity.
🎯 Early detection prevents cardiopulmonary complications and allows for timely administration of calcium gluconate.
🎯Documentation of RR every hour during magnesium therapy is standard practice.
🎯 Also observe for shallow breathing or hypoventilation.
Urine output
🎯 Magnesium is excreted by the kidneys, so adequate urine output is vital to avoid toxicity.
🎯 Output <30 mL/hr may suggest renal impairment or worsening preeclampsia.
🎯 A Foley catheter enables precise hourly measurement, as ordered.
🎯 Oliguria may also be a sign of multi-organ dysfunction in preeclampsia.
🎯 Close tracking helps guide fluid management and magnesium dosing.
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This question is from Custom: NUR209 SU 2 2025 Midpoint Assessment which contains 36 questions.
More Questions from This Exam
A first-time mother presents for a labor check. She is informed that her vaginal exam shows dilated (3 cm). effaced (10096). and fetal station ( -2). The client asks the nurse to explain the meaning of the results. What explanation is the most appropriate response by the nurse?
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A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
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Olivia Martinez is a 32-year-old G2P1 at 34 weeks and 2 days gestation who presents with a persistent frontal headache and blurry vision that started yesterday.
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Patient's data.
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Patient's data.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 0