Pregnancy Induced Hypertension Test Questions

question

The nurse concludes that a client is at risk for pregnancy-induced hypertension (PIH) when the vital signs taken during pregnancy show that the blood pressure increases from: a. 122/80 to 138/86. b. 100/60 to 130/76. c. 90/56 to 110/70. d. 134/80 to 140/88.
answer

b. 100/60 – 130/76 An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for PIH. The other examples do not meet these criteria.
question

The nurse is caring for a woman who has been admitted with early pregnancy-induced hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to: a. Check the blood pressure and fetal heart tones. b. Maintain a patent airway. c. Administer oxygen. d. Prepare to administer magnesium sulfate.
answer

b. patent airway The woman experiencing eclampsia is at great risk for seizures, and the highest priority of care is a patent airway. Checking blood pressure, fetal heart tones, and administering magnesium sulfate and oxygen are all components of care but are of lower priority than maintaining a patent airway.
question

The nurse is evaluating a woman at 48 hours postpartum who experienced pregnancy-induced hypertension (PIH). Which of the following would lead the nurse to conclude that the PIH has not resolved? a. Blood pressure is returned to baseline. b. Client complains of perineal pain. c. Urine output is increasing. d. Client complains of headache and blurred vision.
answer

d. ha and blurred vision Headache and blurred vision are symptoms of the disorder, indicating that the PIH has not resolved. Baseline blood pressure and increasing urine output are signs that PIH is resolving. Perineal pain is unrelated to PIH.
question

The nurse is performing a routine prenatal assessment of a client at 23 weeks’ gestation. Which of the following would indicate to the nurse that the client may be experiencing pregnancy-induced hypertension (PIH)? a. A baseline blood pressure of 122/80. b. Proteinuria. c. Complaints of low back pain. d. Glucose in the urine.
answer

b. proteinuria PIH begins to occur at 20 weeks’ gestation, and proteinuria is one sign that the client is experiencing PIH. A baseline pressure is not a determining factor for PIH. Glucose in the urine indicates possible gestational diabetes, which puts the client at risk for PIH, but is not diagnostic for PIH. Back pain is unrelated to PIH.
question

The nurse is caring for a client with severe preeclampsia who is showing signs of bleeding and oozing from intravenous sites and who is bruising under the skin. The nurse suspects which of the following? a. Transient hypertension. b. Eclampsia. c. Hemolysis, elevated liver enzymes, low platelet count syndrome (HELLP). d. Chronic hypertensive disease.
answer

c. HELLP Pregnant women with severe preeclampsia may develop HELLP syndrome, which has a very poor prognosis. HELLP presents with nausea, vomiting, flulike symptoms, and bleeding due to liver involvement and platelet aggregation. Eclampsia presents with seizures, blurred vision, and high blood pressure. Chronic and transient hypertension may lead to HELLP syndrome.
question

The nurse is caring for a pregnant woman who is admitted with preeclampsia. The nurse plans care based on the nursing diagnosis of deficient fluid volume related to fluid shifts from vasospasms. Which of the following nursing interventions is a priority for this client? (Select all that apply.) a. Place client in the left lateral recumbent position. b. Monitor for increased urine output. c. Weigh client weekly. d. Assess blood pressure every 8 hours. e. Assess deep tendon reflexes.
answer

a. left lateral recumbent position e. deep tendon reflexes The left lateral position reduces pressure on the vena cava, thereby increasing venous return. Hyperreflexia indicates central nervous involvement and is a sign of progression toward eclampsia. Blood pressure is assessed every 1-4 hours. Urine output is decreased in preeclampsia; the client is weighed daily for fluid status.
question

The nurse is instructing a client with mild pregnancy-induced hypertension (PIH) who is about to be discharged home. The nurse teaches the mother to call the physician if which of the following occurs? a. Appetite increases. b. Fetal movement slows or stops. c. Back pain increases. d. Edema decreases.
answer

b. movement slows or stops The fetus is affected by PIH due to maternal vasospasms that decrease blood flow and nutrients to the fetus, which may cause the baby to die if PIH worsens. Back pain and increased appetite are not signs of worsening PIH. Edema increases as PIH progresses.
question

The nurse is caring for a client with severe pregnancy-induced hypertension who is in the hospital on a magnesium sulfate drip. The nurse monitors the client for which of the following signs of magnesium toxicity? a. Slurring of speech. b. Awkward movements. c. Diminished reflexes. d. Decreased appetite.
answer

c. diminished reflexes Diminished reflexes signify magnesium toxicity. Slurred speech, decreased appetite, and awkward movements indicate a therapeutic magnesium level.
question

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? select all a. respirations fewer than 12/min b. urinary output less than 30 mL/hr c. hyperreflexic deep tendon reflexes d. decreased LOC e. flushing and sweating
answer

a. respers less than 12 b. urinary output less than 30 d. decreased LOC c. absence of deep tendon reflexes e. flushing and sweating are adverse effects not s/s of toxicity
question

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? a. nifedipine b. pyridoxine c. ferrous sulfate d. calcium gluconate
answer

d. calcium gluconate is the antidote for magnesium sulfate

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