A pregnant patient at 34 weeks of gestation is diagnosed with preeclampsia and suspected HELLP syndrome. Which immediate nursing intervention is most critical to prevent maternal and fetal complications?

B) Initiate magnesium sulfate therapy and monitor for signs of toxicity.

A) Administer antihypertensive medications to lower blood pressure to normal levels immediately.

B) Initiate magnesium sulfate therapy and monitor for signs of toxicity.

C) Prepare the patient for an immediate cesarean delivery to prevent further complications.

D) Encourage increased fluid intake to manage edema and improve renal perfusion.

A patient with preeclampsia and suspected HELLP syndrome is being treated with magnesium sulfate. During your shift assessment, which finding would require the most immediate nursing intervention?

D) The patient's respiratory rate is 10 breaths per minute.

A) Deep tendon reflexes are +2.

B) The patient reports a headache and visual disturbances.

C) Urinary output over the past hour is 60 mL.

D) The patient's respiratory rate is 10 breaths per minute.

A patient with HELLP syndrome is being prepared for an emergency cesarean section. Which nursing intervention is most critical to perform immediately before the procedure to minimize maternal and fetal risks?

D) Initiate continuous fetal heart monitoring until delivery

A) Ensure the patient is NPO (nothing by mouth) for at least 8 hours

B) Administer a loading dose of magnesium sulfate to prevent seizures

C) Obtain informed consent for the cesarean section

D) Initiate continuous fetal heart monitoring until delivery

A 32-year-old pregnant patient at 35 weeks gestation with diagnosed HELLP syndrome is being prepared for an emergency cesarean section due to signs of fetal distress and maternal complications. Which preoperative nursing intervention is the most critical to prioritize?

D) Ensuring availability of magnesium sulfate to prevent eclamptic seizures during the procedure

A) Administering a bolus of IV fluids to prevent maternal hypotension during anesthesia

B) Preparing the patient for potential blood transfusion by ensuring type and crossmatch is complete

C) Educating the patient and family about postpartum care and potential NICU stay for the newborn

D) Ensuring availability of magnesium sulfate to prevent eclamptic seizures during the procedure

A postpartum patient diagnosed with HELLP syndrome is in the ICU and continues to exhibit elevated blood pressure despite receiving magnesium sulfate and antihypertensive therapy. Which nursing intervention is most appropriate to prevent further complications?

B) Monitor the patient for signs of disseminated intravascular coagulation (DIC).

A) Increase the infusion rate of magnesium sulfate.

B) Monitor the patient for signs of disseminated intravascular coagulation (DIC).

C) Encourage ambulation to promote circulation.

D) Provide high-protein snacks to support liver function.

A patient in labor develops tonic-clonic seizures despite receiving magnesium sulfate, indicating eclampsia. After the seizures subside and the cesarean section is underway, the patient's blood pressure remains elevated. Which nursing intervention should be prioritized to manage this patient's blood pressure and prevent further complications during the procedure?

B) Administer a bolus of intravenous labetalol as prescribed to control hypertension.

A) Increase the infusion rate of magnesium sulfate to reduce blood pressure.

B) Administer a bolus of intravenous labetalol as prescribed to control hypertension.

C) Position the patient in a left lateral position to improve uteroplacental blood flow.

D) Encourage deep breathing exercises to help lower the patient's anxiety and blood pressure.

A patient in the ICU following a cesarean section presents with HELLP syndrome, persistent hypertension, and confusion. What is the priority nursing intervention to address her current condition?

B) Increase the rate of magnesium sulfate infusion.

A) Administer an additional dose of antihypertensive medication.

B) Increase the rate of magnesium sulfate infusion.

C) Prepare for an immediate CT scan of the head.

D) Administer fresh frozen plasma to correct coagulopathy.

A postpartum patient in the ICU following a cesarean section is receiving treatment for HELLP syndrome with persistent hypertension and neurological symptoms. Despite antihypertensive therapy, her blood pressure remains at 160/100 mmHg, and she is receiving magnesium sulfate to prevent seizures. What is the priority nursing intervention at this time?

C) Monitor for signs of magnesium toxicity.

A) Increase the rate of magnesium sulfate infusion.

B) Administer additional antihypertensive medication as ordered.

C) Monitor for signs of magnesium toxicity.

D) Assess the patient's pain level and provide analgesia.

A patient receiving magnesium sulfate for eclampsia develops lethargy and a GCS score of 10. After treating for potential magnesium toxicity, her GCS improves to 13. Which of the following nursing actions is most appropriate to prioritize next?

B) Monitor the patient’s deep tendon reflexes every hour to assess for signs of toxicity.

A) Resume the original rate of magnesium sulfate infusion to maintain therapeutic levels.

B) Monitor the patient’s deep tendon reflexes every hour to assess for signs of toxicity.

C) Administer an additional bolus of calcium gluconate to further counteract magnesium effects.

D) Increase the frequency of blood pressure monitoring to every 15 minutes to manage hypertension.

A postpartum patient receiving magnesium sulfate infusion becomes lethargic with a Glasgow Coma Scale (GCS) score of 10. Her serum magnesium level is 5.8 mg/dL. Which of the following actions should the nurse prioritize to address potential magnesium toxicity while ensuring patient safety?

B) Administer intravenous calcium gluconate as prescribed to counteract magnesium toxicity.

A) Increase the rate of the magnesium sulfate infusion to ensure therapeutic levels.

B) Administer intravenous calcium gluconate as prescribed to counteract magnesium toxicity.

C) Encourage oral fluid intake to enhance magnesium excretion.

D) Discontinue the magnesium sulfate infusion permanently.

Maternity - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal regulation - Pregnancy involves increased production of hormones like progesterone and estrogen, essential for maintaining the uterine lining, promoting fetal growth, and preparing the mother's body for childbirth.

• Secondary mechanism: Cardiovascular adaptation - Blood volume increases significantly to supply adequate nutrients and oxygen to the fetus, leading to increased cardiac output and potential hemodynamic changes, which can predispose to conditions like gestational hypertension.

• Key complication: Gestational diabetes - Hormonal changes can lead to insulin resistance, increasing maternal blood glucose levels and posing risks such as fetal macrosomia, preeclampsia, and the need for cesarean delivery.

Patient Profile

Demographics:

32 years old, female, school teacher

History:

• Key past medical history: Gestational diabetes in previous pregnancy, hypothyroidism

• Current medications: Levothyroxine 75 mcg daily, prenatal vitamins

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headache and swelling in feet

• Key symptoms: Elevated blood pressure, dizziness, mild shortness of breath

• Vital signs: Blood pressure 150/95 mmHg, heart rate 92 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F

Section 1

As the nurse conducts an initial assessment, further examination reveals notable pitting edema in the patient's lower extremities and mild proteinuria detected through a urine dipstick test. The patient's blood pressure remains elevated at 152/98 mmHg, with a repeat reading confirming the hypertensive state. Given her history of gestational diabetes and current symptoms, the risk of developing preeclampsia becomes a significant concern. Laboratory tests are ordered, including a complete blood count (CBC), liver function tests, and serum electrolytes, as well as a 24-hour urine collection to quantify proteinuria.

The new diagnostic results indicate elevated liver enzymes and a platelet count at the lower end of normal, raising suspicion for the development of HELLP syndrome, a severe form of preeclampsia. The 24-hour urine collection confirms significant proteinuria, further supporting the diagnosis. The patient's blood glucose levels remain within target ranges, suggesting her gestational diabetes is well-controlled at this time. However, the presence of these new findings requires immediate clinical reasoning to prevent further complications.

In response to these developments, the healthcare team initiates magnesium sulfate therapy to prevent seizures and closely monitors the patient's fluid status, blood pressure, and fetal well-being. The obstetrician discusses the potential need for early delivery, balancing the risks of prematurity with the maternal and fetal risks posed by progressing preeclampsia. These clinical decisions highlight the importance of interdisciplinary collaboration and patient-centered care in managing complex pregnancy complications. As the patient is transferred to a higher level of care for closer monitoring, the team remains vigilant for any signs of deterioration or new complications.

Section 2

As the patient is closely monitored in the higher level of care unit, the healthcare team conducts frequent assessments to detect any changes in her condition. Despite the administration of magnesium sulfate, the patient begins to exhibit new symptoms, including increased headache, visual disturbances such as seeing "floaters," and an escalating sense of anxiety. Her blood pressure remains elevated, with readings now fluctuating between 160/102 mmHg and 170/110 mmHg, indicating a lack of sufficient response to current antihypertensive therapy.

Laboratory results reveal further deterioration, with liver enzymes continuing to rise and a dropping platelet count now reaching a critically low level of 85,000/mm^3. Concurrently, fetal monitoring indicates concerning patterns, such as decreased variability and the appearance of late decelerations, suggesting the potential for fetal distress. These findings prompt the healthcare team to re-evaluate the management plan, taking into account the risks of maternal complications such as eclampsia or disseminated intravascular coagulation (DIC) and the urgent need to optimize fetal outcomes.

The obstetrician, in consultation with maternal-fetal medicine and neonatology specialists, discusses the benefits and risks of immediate delivery with the patient and her family. Given the progression of HELLP syndrome and signs of fetal compromise, the decision is made to proceed with an emergency cesarean section. This decision underscores the critical balance between prolonging the pregnancy for fetal maturity and preventing severe maternal and fetal complications. The team prepares for the operation with a detailed plan to address potential intraoperative and postoperative challenges, ensuring both maternal stabilization and neonatal resuscitation capabilities are prioritized.

Section 3

As the healthcare team swiftly transitions the patient to the operating room for an emergency cesarean section, a new complication arises. Just prior to the induction of anesthesia, the patient experiences a sudden onset of tonic-clonic seizures, indicative of eclampsia, despite the ongoing administration of magnesium sulfate. The anesthesiologist quickly administers an additional bolus of magnesium sulfate and prepares for rapid sequence induction to secure the airway, while the obstetric team urgently coordinates for the expedited delivery. The seizure subsides within minutes, but the situation underscores the critical instability of the patient’s condition.

Following the stabilization of the patient's airway and the initiation of anesthesia, the cesarean section proceeds. Throughout the procedure, the patient’s blood pressure remains elevated, necessitating the careful titration of antihypertensive medications. The surgical team encounters excessive bleeding upon uterine incision, exacerbated by the patient’s underlying coagulopathy due to the low platelet count and elevated liver enzymes—a hallmark of HELLP syndrome. The obstetrician, anticipating this complication, had pre-arranged for blood products to be readily available. A transfusion of platelets and fresh frozen plasma is promptly administered to mitigate the risk of disseminated intravascular coagulation (DIC) and to stabilize the patient's hemostatic status.

The newborn is delivered with signs of respiratory distress and is immediately handed over to the neonatology team for resuscitation. The Apgar scores are initially low, but with appropriate neonatal interventions, the infant begins to show signs of improvement. Meanwhile, the obstetric team continues to manage the mother’s bleeding and monitors for any further complications. Postoperatively, the patient is transferred to the intensive care unit for continued close monitoring and management of her blood pressure, coagulation status, and potential for further seizures. The rapid response and coordinated efforts of the multidisciplinary team highlight the complexities and critical decision-making processes inherent in managing severe obstetric emergencies.

Section 4

Following the cesarean section, the patient is now in the intensive care unit, where the healthcare team conducts an initial assessment to establish her baseline status. Her vital signs indicate persistent hypertension, with a blood pressure of 160/100 mmHg despite the administration of antihypertensive medications. The patient's heart rate is tachycardic at 110 beats per minute, and her respiratory rate is slightly elevated at 22 breaths per minute. Oxygen saturation is maintained at 95% on supplemental oxygen. Neurologically, she is responsive but exhibits confusion and disorientation, raising concerns about ongoing cerebral involvement from eclampsia.

Laboratory results provide further insights into her condition. Her platelet count remains low at 70,000/μL, and liver function tests show elevated AST and ALT levels at 150 U/L and 170 U/L, respectively, confirming the severity of her HELLP syndrome. Coagulation studies reveal a prolonged PT and aPTT, suggesting a lingering risk for disseminated intravascular coagulation. The patient's renal function, however, shows a mild improvement, with creatinine levels decreasing to 1.2 mg/dL, indicating some recovery of renal perfusion post-delivery.

As the team reviews these findings, they recognize the need for closely monitoring the patient's neurological status and blood pressure. They adjust her treatment plan to include continuous magnesium sulfate infusion to prevent further seizures and optimize antihypertensive therapy. The patient is given additional fresh frozen plasma to address coagulopathy, and a repeat assessment is scheduled to evaluate her response. The team remains vigilant for signs of hemorrhage or organ dysfunction, understanding that the next 24 to 48 hours are critical in her recovery. This ongoing, dynamic assessment and intervention strategy underscores the importance of interdisciplinary collaboration in managing complex maternal cases.

Section 5

As the team continues to monitor the patient, they observe a change in her neurological status. Approximately six hours after the initiation of continuous magnesium sulfate infusion, the patient becomes increasingly lethargic and less responsive to verbal stimuli. Her Glasgow Coma Scale (GCS) score drops to 10, with a noted decrease in eye-opening and motor response. This prompts an urgent reevaluation of her condition to discern whether her altered mental status is a consequence of magnesium toxicity or worsening cerebral involvement from eclampsia.

In response to these concerning signs, the team performs a bedside neurological assessment and orders an immediate serum magnesium level, which reveals a concentration of 5.8 mg/dL, slightly above the therapeutic range. The decision is made to temporarily hold the magnesium sulfate infusion and administer calcium gluconate to counteract potential toxicity. Concurrently, a CT scan of the head is performed to rule out intracranial hemorrhage or significant cerebral edema, both of which could explain her declining neurological function. The imaging does not reveal any acute intracranial events, suggesting that the magnesium level likely contributed to her altered state.

Within an hour of the intervention, the patient shows signs of improvement. Her GCS score rises to 13, and she becomes more oriented, responding appropriately to questions. The team resumes the magnesium infusion at a reduced rate and continues close monitoring. Her blood pressure remains elevated at 158/98 mmHg, prompting a reassessment of her antihypertensive regimen to achieve better control. The interdisciplinary team remains on high alert for further complications, knowing that the next several hours are pivotal in stabilizing her condition and preventing any new issues from arising. This situation highlights the critical need for careful balance and timing in managing complex postpartum complications, ensuring that interventions are both effective and safe.