Obstetrics and Nurse
Preeclampsia
Sara Bishop, RN, PhD
Initial History and Assessment
At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, "I felt like that when I had toxemia during my pregnancy."
Admission assessment by the nurse reveals: today's weight 182 pounds, T 99.1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus.
The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
1. In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Jennie's risk of developing preeclampsia? (Select all that apply.)
A) Molar pregnancy and history of preeclampsia in previous pregnancy.
B) Familial history.
C) History of pounding headache, low socioeconomic status.
D) Preexisting medical or genetic condition, like Factor V Leiden.
E) Nulliparity
2. To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain?
A) Pattern and number of prenatal visits.
B) Prenatal blood pressure readings.
C) Prepregnancy weight.
D) Jennie's Rh factor.
Pathophysiology of Preeclampsia
There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of
Sara Bishop, RN, PhD
Initial History and Assessment
At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, "I felt like that when I had toxemia during my pregnancy."
Admission assessment by the nurse reveals: today's weight 182 pounds, T 99.1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus.
The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
1. In reviewing Jennie's history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Jennie's risk of developing preeclampsia? (Select all that apply.)
A) Molar pregnancy and history of preeclampsia in previous pregnancy.
B) Familial history.
C) History of pounding headache, low socioeconomic status.
D) Preexisting medical or genetic condition, like Factor V Leiden.
E) Nulliparity
2. To accurately assess this client's condition, what information from the prenatal record is most important for the nurse to obtain?
A) Pattern and number of prenatal visits.
B) Prenatal blood pressure readings.
C) Prepregnancy weight.
D) Jennie's Rh factor.
Pathophysiology of Preeclampsia
There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of