A patient with heart failure presents with worsening shortness of breath, paroxysmal nocturnal dyspnea, and pulmonary congestion. The care team initiates diuretic therapy and considers adding an ACE inhibitor. Which of the following nursing interventions is most critical to prioritize during the first 24 hours of diuretic therapy?

C) Assessing the patient's daily weight and urine output

A) Monitoring the patient's blood pressure every 4 hours

B) Educating the patient about the signs of electrolyte imbalance

C) Assessing the patient's daily weight and urine output

D) Evaluating the patient's understanding of dietary sodium restrictions

A patient with heart failure presents with worsening shortness of breath, paroxysmal nocturnal dyspnea, and increased peripheral edema. An echocardiogram reveals a reduced ejection fraction of 40%, and a chest X-ray confirms pulmonary edema. Which nursing intervention should the nurse prioritize to address the patient's immediate symptoms?

A) Administer oxygen therapy to maintain an oxygen saturation above 92%.

B) Encourage the patient to perform deep breathing exercises to improve lung expansion.

C) Advise the patient to increase fluid intake to prevent dehydration.

D) Position the patient in a supine position to promote venous return.

A pregnant patient with a history of heart failure is admitted with symptoms suggestive of preeclampsia, including elevated blood pressure, headache, visual disturbances, and proteinuria. Which nursing intervention is most critical in the immediate management of this patient to prevent further complications?

A) Administer magnesium sulfate as ordered to prevent seizures.

B) Educate the patient on dietary sodium restriction to manage hypertension.

C) Initiate continuous fetal monitoring to assess fetal well-being.

D) Encourage the patient to ambulate to prevent deep vein thrombosis.

A pregnant patient with a history of heart failure is admitted with suspected preeclampsia. Her current treatment includes magnesium sulfate and antihypertensive therapy. Which nursing intervention is the most critical to prioritize to ensure both maternal and fetal safety?

D) Apply external fetal monitoring to continuously assess fetal well-being.

A) Encourage the patient to ambulate frequently to prevent deep vein thrombosis.

B) Monitor the patient's urine output hourly to assess renal function and fluid balance.

C) Educate the patient on a low-sodium diet to help manage blood pressure.

D) Apply external fetal monitoring to continuously assess fetal well-being.

A patient in the maternal-fetal unit with a history of heart failure and preeclampsia presents with increased dyspnea at rest, orthopnea, and crackles upon lung auscultation. Her oxygen saturation is 92% on room air, and her echocardiogram shows a reduced ejection fraction. Which nursing intervention is most appropriate to implement first?

A) Administer supplemental oxygen to improve oxygenation

B) Increase the dosage of beta-blocker to control heart rate

C) Encourage the patient to lie flat to promote rest

D) Prepare the patient for an immediate cesarean section due to fetal distress

A pregnant patient with a history of worsening heart failure is admitted to the maternal-fetal unit with a respiratory rate of 28 breaths per minute and an oxygen saturation of 92% on room air. The interdisciplinary team has initiated low-dose beta-blocker therapy and optimized diuretic therapy. Which nursing intervention is most critical to implement immediately to address the patient's current symptoms and condition?

C) Elevate the head of the bed and administer supplemental oxygen as ordered.

A) Encourage the patient to lie flat to promote better blood flow.

B) Monitor the patient's weight daily to assess fluid retention.

C) Elevate the head of the bed and administer supplemental oxygen as ordered.

D) Restrict the patient's fluid intake to prevent fluid overload.

A nurse is caring for a patient diagnosed with HELLP syndrome and worsening hypertension at 34 weeks of gestation. The multidisciplinary team has decided to expedite delivery. Which of the following nursing interventions is most critical to prioritize in preparing the patient for delivery?

B) Administer prescribed magnesium sulfate to prevent seizures.

A) Initiate continuous fetal heart rate monitoring to assess fetal well-being.

B) Administer prescribed magnesium sulfate to prevent seizures.

C) Educate the patient and family about postpartum care and expectations.

D) Prepare the patient for a non-stress test to evaluate fetal activity.

A patient with a diagnosis of HELLP syndrome is scheduled for an expedited delivery due to worsening maternal condition. Which nursing intervention is the priority to ensure both maternal and fetal safety during this critical period?

C) Monitor maternal blood pressure and administer antihypertensive medications as ordered

A) Administer prescribed corticosteroids to accelerate fetal lung maturity

B) Initiate continuous electronic fetal monitoring

C) Monitor maternal blood pressure and administer antihypertensive medications as ordered

D) Prepare the patient for possible blood transfusion due to low platelet count

A nurse is preparing to assist in the delivery of a patient with worsening HELLP syndrome and signs of cardiac instability. Which immediate intervention should the nurse anticipate to best support the patient's respiratory status during this critical period?

B) Prepare for endotracheal intubation and mechanical ventilation

A) Administer intravenous antibiotics to prevent infection

B) Prepare for endotracheal intubation and mechanical ventilation

C) Increase the rate of intravenous fluids to maintain blood pressure

D) Apply continuous nasogastric suction to reduce nausea

A patient with HELLP syndrome is being prepared for an emergency cesarean delivery due to worsening maternal condition and fetal distress. Which of the following interventions should the nurse prioritize to address the patient's current symptoms and prevent further complications?

C) Implement seizure precautions and prepare for potential post-operative bleeding.

A) Administer IV magnesium sulfate to prevent seizures.

B) Increase the rate of the diuretic infusion to reduce pulmonary congestion.

C) Implement seizure precautions and prepare for potential post-operative bleeding.

D) Request an immediate transfusion of platelets to correct the low platelet count.

CHF in pregnancy - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased blood volume during pregnancy leads to higher cardiac output demands. In patients with compromised cardiac function, the heart struggles to manage this load, potentially precipitating heart failure.

• Secondary mechanism: Hormonal changes, particularly elevated progesterone levels, cause vasodilation and fluid retention. This increases cardiac workload and can exacerbate pre-existing cardiac insufficiency.

• Key complication: Reduced cardiac output can lead to pulmonary congestion, causing symptoms such as dyspnea and fatigue, which are critical for nurses to monitor and manage in pregnant patients with CHF.

Patient Profile

Demographics:

32-year-old female, school teacher

History:

• Key past medical history: Diagnosed with chronic hypertension, history of mild mitral valve prolapse, previous pregnancy with gestational diabetes

• Current medications: Labetalol, prenatal vitamins, low-dose aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and fatigue

• Key symptoms: Persistent cough, swelling in lower extremities, orthopnea, palpitations

• Vital signs: Blood pressure 145/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air

Section 1

As the clinical team continues to manage the patient's condition, they note a change in her status that warrants immediate attention. During a routine assessment, the patient reports worsening shortness of breath, now accompanied by paroxysmal nocturnal dyspnea. Her swelling in the lower extremities has increased, and she describes a sensation of fullness in her abdomen. On examination, her vital signs indicate a blood pressure of 150/100 mmHg and a heart rate of 115 bpm. The respiratory rate has increased to 24 breaths per minute, and her oxygen saturation has dropped further to 89% on room air. Auscultation of the lungs reveals bilateral crackles, particularly in the lower lobes, suggesting pulmonary congestion. The presence of jugular venous distension and a positive hepatojugular reflux test further suggests right-sided heart strain.

Concerned about the progression of her symptoms, the care team orders a series of diagnostic tests to evaluate the extent of cardiac compromise. An echocardiogram shows a reduced ejection fraction of 40%, indicating systolic dysfunction. Additionally, a chest X-ray confirms pulmonary edema with mild cardiomegaly. Laboratory results reveal an elevated B-type natriuretic peptide (BNP) level, consistent with heart failure. Her renal function is closely monitored, and while serum creatinine and blood urea nitrogen remain within normal limits, there is concern about potential renal impairment due to decreased cardiac output.

These findings prompt the team to adjust her management plan. Diuretic therapy is initiated with a low dose of furosemide to manage fluid overload while monitoring electrolyte levels closely. The team considers the need for further cardiac support and contemplates the addition of an ACE inhibitor, keeping her penicillin allergy in mind. The patient is educated on daily weight monitoring and signs of worsening heart failure. Close follow-up appointments are scheduled to assess her response to the revised treatment plan, with an emphasis on early identification of potential new complications, such as worsening renal function or preeclampsia, which could further complicate her pregnancy and overall health.

Section 2

As the care team closely monitors the patient's response to the adjusted treatment plan, they note her initial improvement with diuretic therapy. Her lower extremity swelling decreases slightly, and she reports feeling less abdominal fullness. However, during a follow-up visit, the patient mentions experiencing a persistent headache and visual disturbances, including blurred vision and seeing spots. These new symptoms raise concern for potential preeclampsia, a condition that could exacerbate her cardiac issues and pose significant risks to both mother and fetus.

A comprehensive assessment is promptly conducted. The patient's blood pressure now reads 160/105 mmHg, and her heart rate remains elevated at 110 bpm. A urinalysis reveals the presence of proteinuria, further supporting the suspicion of preeclampsia. Given these findings, the clinical team decides to admit the patient for more intensive monitoring and management. Magnesium sulfate is considered to prevent seizures, and antihypertensive therapy is initiated to manage her blood pressure. The interdisciplinary team, including a maternal-fetal medicine specialist, collaborates to balance the needs of managing her heart failure with the emerging complications of preeclampsia.

The team recognizes the critical nature of this intersection between cardiac and obstetric care. They emphasize continuous fetal monitoring and prepare for potential preterm delivery if the mother's condition deteriorates. The patient is educated on the importance of reporting any new symptoms immediately and is reassured about the comprehensive care plan in place. The focus remains on stabilizing her condition while minimizing risks to the fetus, with the team's strategy evolving as they anticipate and address further complications. This careful orchestration of her care highlights the complexity of managing concurrent cardiac and obstetric issues and sets the stage for the next steps in her treatment journey.

Section 3

As the patient settles into the hospital's maternal-fetal unit for closer observation, the interdisciplinary team closely monitors her for any changes in status. Despite initial management efforts, the patient begins to exhibit signs of worsening heart failure. Her respiratory rate increases to 28 breaths per minute, and she reports a new onset of dyspnea at rest, accompanied by orthopnea and paroxysmal nocturnal dyspnea. Her oxygen saturation levels drop to 92% on room air, prompting the team to provide supplemental oxygen to maintain adequate levels. Auscultation reveals crackles in the lung bases, indicating pulmonary congestion.

Laboratory tests reveal an elevation in B-type natriuretic peptide (BNP) levels, consistent with exacerbation of heart failure. The patient's echocardiogram, repeated to assess her cardiac function, shows a reduced ejection fraction of 35%, suggesting decreased cardiac output. This new information complicates her clinical picture, necessitating a delicate balance in her treatment approach. The team decides to initiate low-dose beta-blocker therapy to manage her tachycardia while cautiously optimizing diuretic therapy to address her fluid overload, all under the careful supervision of the maternal-fetal medicine specialist.

The evolving scenario prompts the team to reassess the risk of preterm delivery, a decision weighed heavily against the potential benefits of prolonging the pregnancy to improve fetal outcomes. They continue rigorous fetal monitoring, noting reassuring but closely watched fetal heart rate patterns. Meanwhile, the patient's family is engaged in conversations about the potential need for early delivery if her condition deteriorates further. Through these challenges, the care team remains vigilant, adapting their strategies to navigate the complexities of concurrent heart failure and preeclampsia in pregnancy.

Section 4

As the medical team continues to monitor the patient, new complications arise that necessitate immediate attention. Despite the introduction of beta-blockers and diuretics, the patient's condition has not improved as anticipated. Her blood pressure begins to rise, with readings consistently around 160/100 mmHg, indicating poorly controlled hypertension. This development raises concerns about worsening preeclampsia, especially given the patient's history and current symptoms. The team orders additional laboratory tests, revealing elevated liver enzymes (AST and ALT) and a further decrease in platelet count, confirming the suspicion of HELLP syndrome, a severe form of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelet count.

These findings prompt an urgent multidisciplinary meeting to reassess the patient's management plan. The maternal-fetal medicine specialist, cardiologist, and neonatologist discuss the risks associated with continuing the pregnancy against the immediate need to stabilize the mother's condition. With the dual threat of heart failure exacerbation and HELLP syndrome, the team recognizes that the maternal risks now outweigh the benefits of prolonging the pregnancy. They decide to prepare for an expedited delivery, balancing the need for maternal safety with the hope of optimizing neonatal outcomes.

In preparation for delivery, the care team intensifies fetal monitoring and begins administering corticosteroids to accelerate fetal lung maturity, recognizing the imminent risk of preterm birth. An anesthesiology consult is obtained to evaluate the safest method for delivery, considering the patient's cardiac status. The patient's family is updated on the situation, with emphasis placed on the urgency of the intervention and the collaborative efforts being made to ensure the best possible outcomes for both mother and child. The team's clinical reasoning now focuses on executing a safe delivery plan while preparing for any potential post-delivery complications in the context of the patient's complex clinical picture.

Section 5

As the team prepares for delivery, the patient's condition continues to evolve, warranting close observation. During the pre-delivery assessment, the nurse notes that the patient appears increasingly fatigued and pale, with a mild tremor in her hands. Her heart rate has risen to 120 beats per minute, suggesting possible tachycardia, while her respiratory rate is elevated at 28 breaths per minute. The nurse performs a focused cardiac and respiratory assessment, revealing bilateral crackles in the lung bases, indicative of potential pulmonary congestion due to fluid overload, despite ongoing diuretic therapy. The patient's oxygen saturation has dropped to 90% on room air, prompting the initiation of supplemental oxygen to maintain adequate oxygenation.

Concurrent with these findings, new laboratory results arrive, showing further deterioration in the patient's liver function: AST and ALT levels have doubled from previous readings, and her platelet count has plummeted to 80,000/mm³. These changes confirm the progression of HELLP syndrome, heightening the urgency for delivery. The patient's coagulation profile is also reviewed, revealing an elevated INR of 1.5, which complicates the anesthesiology team's options for safe delivery. Given the patient's cardiac instability and coagulation status, the anesthesiologist recommends proceeding with a cesarean delivery under general anesthesia, despite the increased risks, to quickly address the worsening maternal condition.

The team acts swiftly, coordinating the logistics of the imminent delivery while preparing for the potential need for post-operative cardiac support and management of bleeding. Neonatal specialists are on standby, ready to provide immediate care for the preterm infant, who is anticipated to require respiratory support. The clinical reasoning now centers on balancing rapid delivery to mitigate maternal risks while ensuring that neonatal care plans are in place to address the challenges of prematurity. As the patient is moved to the operating room, the multidisciplinary team's seamless collaboration underscores the critical importance of timely intervention in managing complex obstetric and cardiac emergencies.