A 28-year-old patient with a history of gestational diabetes and hypertension is being monitored for pre-eclampsia with severe features. Which nursing intervention is the most critical to implement immediately upon initiating a magnesium sulfate infusion?

B) Assess the patient's respiratory rate and oxygen saturation continuously.

A) Monitor the patient's deep tendon reflexes every 4 hours.

B) Assess the patient's respiratory rate and oxygen saturation continuously.

C) Measure the patient's blood pressure every 30 minutes.

D) Evaluate the patient's urine output every 2 hours.

A 28-year-old patient with a history of gestational diabetes and hypertension has been diagnosed with pre-eclampsia with severe features. Upon assessment, she presents with 2+ pitting edema, mild jugular venous distension, and worsening shortness of breath when lying flat. Her lab results show elevated liver enzymes and low platelet count. What is the priority nursing intervention to address the current clinical manifestations before further deterioration?

B) Position the patient in a semi-Fowler's position to improve breathing

A) Administer antihypertensive medication to lower blood pressure

B) Position the patient in a semi-Fowler's position to improve breathing

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

D) Prepare for immediate delivery to prevent maternal and fetal complications

A patient receiving magnesium sulfate for severe preeclampsia shows signs of potential magnesium toxicity. Which of the following nursing interventions is most appropriate to perform first?

A) Assess the patient's deep tendon reflexes.

B) Administer calcium gluconate.

C) Discontinue the magnesium sulfate infusion.

D) Increase the patient's oxygen flow rate.

A patient receiving magnesium sulfate for severe preeclampsia is being monitored. Which assessment finding should prompt the nurse to take immediate action?

C) Blood pressure of 165/105 mmHg

D) Fetal heart rate with moderate variability

A 32-year-old pregnant patient at 34 weeks gestation presents with severe headache, blurred vision, and elevated blood pressure of 170/110 mmHg. Laboratory tests show elevated liver enzymes and a low platelet count, indicating HELLP syndrome. Fetal monitoring reveals moderate variability with frequent late decelerations. What is the priority nursing intervention at this time?

A) Administer magnesium sulfate to prevent seizures.

B) Prepare for potential immediate cesarean section.

C) Increase the dose of antihypertensive medication.

D) Provide the patient with a low-sodium diet.

A patient with suspected HELLP syndrome presents with blood pressure readings of 170/110 mmHg, a severe headache, visual disturbances, and lab results indicating elevated liver enzymes and low platelet count. Fetal monitoring shows late decelerations. What is the most appropriate immediate nursing action to prioritize the safety of both the mother and fetus?

B) Initiate magnesium sulfate therapy to prevent seizures.

A) Administer an antihypertensive medication to lower the blood pressure.

B) Initiate magnesium sulfate therapy to prevent seizures.

C) Increase IV fluid rate to improve maternal circulation.

D) Prepare the patient for an immediate cesarean section.

A patient with HELLP syndrome is being prepared for an emergency cesarean section. Which of the following nursing interventions should be prioritized to prevent complications during the procedure?

C) Monitor the patient's reflexes and clonus closely to assess for magnesium toxicity.

A) Administer a bolus of intravenous fluids to ensure adequate hydration.

B) Prepare for blood transfusion due to the patient's low platelet count.

C) Monitor the patient's reflexes and clonus closely to assess for magnesium toxicity.

D) Position the patient in a left lateral position to optimize fetal circulation.

A patient with suspected HELLP syndrome is experiencing intense headache, visual disturbances, and elevated blood pressure despite antihypertensive therapy. Which immediate nursing action is most crucial to address her current condition?

B) Initiate seizure precautions and prepare magnesium sulfate for administration.

A) Administer additional oral antihypertensive medication as prescribed.

B) Initiate seizure precautions and prepare magnesium sulfate for administration.

C) Reassess the fetal heart rate every hour to monitor for distress.

D) Encourage the patient to rest in a dark, quiet room to alleviate headache symptoms.

A pregnant patient undergoing an emergency cesarean section is receiving magnesium sulfate for severe preeclampsia. She exhibits respiratory depression with a respiratory rate of 8 breaths per minute and oxygen saturation of 89%. What immediate nursing action is most appropriate to address this situation?

A) Administer a calcium gluconate antidote as ordered

B) Increase the infusion rate of magnesium sulfate

C) Place the patient in Trendelenburg position

D) Encourage deep breathing exercises

A nurse is caring for a patient in the operating room undergoing an emergency cesarean section due to fetal distress and maternal respiratory depression. Which of the following is the most critical nursing action to ensure maternal and fetal safety during this procedure?

D) Adjust the patient’s position to improve respiratory function and oxygenation.

A) Continuously monitor the patient’s blood pressure to manage hypertensive crisis.

B) Administer additional doses of magnesium sulfate to prevent seizures.

C) Prepare for neonatal resuscitation by ensuring the presence of a pediatric team.

D) Adjust the patient’s position to improve respiratory function and oxygenation.

pregnancy - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal changes - Pregnancy triggers increased production of hormones such as human chorionic gonadotropin (hCG), estrogen, and progesterone. These hormones maintain the uterine lining, support fetal development, and prepare the body for childbirth and lactation.

• Secondary mechanism: Cardiovascular adaptations - Blood volume and cardiac output increase to supply sufficient oxygen and nutrients to the fetus. This can lead to physiological changes such as increased heart rate and decreased systemic vascular resistance, ensuring effective circulation for both mother and fetus.

• Key complication: Gestational hypertension - This condition arises from the inability of maternal blood vessels to adequately remodel, leading to high blood pressure. It poses risks for both mother and fetus, including pre-eclampsia and intrauterine growth restriction, necessitating careful monitoring and management.

Patient Profile

Demographics:

28-year-old female, nurse

History:

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

• Current medications: Prenatal vitamins, labetalol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath and swelling in the legs

• Key symptoms: Fatigue, persistent headache, elevated blood pressure, occasional dizziness

• Vital signs: Blood pressure 150/95 mmHg, heart rate 98 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 95% on room air

Section 1

As the healthcare team continues to assess the 28-year-old patient with a history of gestational diabetes and hypertension, further evaluation reveals significant findings that necessitate swift clinical reasoning. Upon conducting a thorough physical examination, the nurse notes 2+ pitting edema in the lower extremities and mild jugular venous distension, suggesting fluid overload. The patient reports that her shortness of breath worsens when lying flat, a symptom indicative of possible pulmonary involvement. Moreover, her persistent headache has become more severe and is not relieved by over-the-counter analgesics, raising concerns about her neurological status.

Laboratory results return, revealing elevated liver enzymes (AST 65 U/L, ALT 58 U/L) and a platelet count of 95,000/mm³. These findings, combined with her hypertension and other symptoms, suggest the development of pre-eclampsia with severe features. Proteinuria is confirmed with a urine protein-to-creatinine ratio of 0.35, further supporting the diagnosis. The patient's blood pressure remains elevated despite current medication, and her oxygen saturation has dropped slightly to 93% on room air, indicating a potential compromise in respiratory function.

In light of these developments, the healthcare team initiates a magnesium sulfate infusion to prevent seizures and considers corticosteroid administration to enhance fetal lung maturity, given the possibility of preterm delivery. Continuous fetal monitoring is implemented to assess fetal well-being, while the team prepares for the possibility of expedited delivery if maternal or fetal conditions deteriorate. The interdisciplinary approach focuses on stabilizing the patient's condition while optimizing outcomes for both mother and child, highlighting the need for careful monitoring and timely intervention.

Section 2

Response to Interventions

Following the initiation of the magnesium sulfate infusion, the healthcare team closely monitors the patient for any signs of magnesium toxicity, including respiratory depression, loss of deep tendon reflexes, and altered mental status. The infusion appears to be well-tolerated initially, with the patient maintaining a respiratory rate of 16 breaths per minute and intact reflexes. However, her blood pressure continues to be a concern, with readings averaging 165/105 mmHg, prompting the team to adjust her antihypertensive regimen, adding labetalol to her treatment plan to improve blood pressure control. The nursing staff is vigilant in monitoring for any adverse effects and ensures that calcium gluconate is readily available as an antidote for magnesium toxicity if needed.

As corticosteroids are administered to promote fetal lung maturity, the patient reports feeling slightly more short of breath, and her oxygen saturation briefly dips to 91% on room air. The healthcare team responds by administering supplemental oxygen via nasal cannula, which improves her saturation to 95%. Despite these interventions, the patient remains uncomfortable, expressing ongoing discomfort from her headache and a sense of unease about her health and that of her baby. The team reassures her while maintaining a high level of alertness for any signs of disease progression.

Continuous fetal monitoring indicates moderate variability in the fetal heart rate with occasional late decelerations, suggesting potential fetal distress. This prompts a reevaluation of the maternal-fetal status by the obstetrics team, who discusses with the patient the possibility of expedited delivery should the fetal condition worsen or maternal status further deteriorate. The team prepares for potential delivery by ensuring that the necessary surgical and neonatal teams are on standby, highlighting the importance of interdisciplinary coordination in managing this complex clinical situation.

Section 3

As the nursing staff continues to monitor the patient, they observe a sudden increase in her headache severity, which is now accompanied by visual disturbances such as blurred vision and seeing spots. The patient's blood pressure remains elevated at 170/110 mmHg despite the adjusted antihypertensive regimen. Concerned about the potential progression to eclampsia, the healthcare team increases the frequency of neurological assessments and decides to perform additional diagnostic tests, including a complete blood count (CBC) and comprehensive metabolic panel (CMP), to gather more information on her condition.

The laboratory results reveal a slight elevation in liver enzymes and a drop in platelet count, suggesting the development of HELLP syndrome, a severe form of preeclampsia. This complication requires immediate attention, and the team discusses the need for further intervention to stabilize both the mother and the fetus. The fetal monitoring continues to show moderate variability with more frequent late decelerations, heightening the concern for fetal distress.

Recognizing the gravity of the situation, the obstetrics team and patient engage in a critical discussion regarding the benefits and risks of an expedited delivery. The patient is counseled on the potential need for a cesarean section should her condition or the fetal status deteriorate further. The team emphasizes the importance of maternal and fetal well-being and the need for timely intervention. As the staff prepares for all possible outcomes, they remain committed to delivering high-quality, empathetic care while ensuring the patient's understanding and involvement in her treatment plan.

Section 4

As the healthcare team closely monitors the patient, they note a further change in her status. Her headache becomes more intense, and she reports worsening visual disturbances, describing them as persistent flashes of light. The patient's blood pressure spikes to 180/115 mmHg despite the continued administration of antihypertensive medications, indicating a potential escalation of her hypertensive crisis. Neurological assessments reveal increased reflexes and clonus, suggesting heightened neurological irritability and raising the suspicion of impending eclampsia.

In response, the team rapidly administers intravenous magnesium sulfate to prevent seizures and continue to manage her blood pressure aggressively. A repeat complete blood count (CBC) shows a worrying trend: her platelet count has dropped further to 85,000/mm³, and her liver enzymes are now markedly elevated, with AST at 100 U/L and ALT at 95 U/L. These findings confirm the progression of HELLP syndrome, necessitating urgent action to prevent further maternal and fetal compromise.

With fetal monitoring indicating persistent late decelerations and reduced variability suggestive of fetal distress, the team convenes quickly to reassess the situation. The obstetrics team discusses the urgent need for delivery to ensure the safety of both mother and child. The patient is prepped for a cesarean section, with the understanding that prompt delivery is the most viable option to mitigate the risks associated with her rapidly deteriorating condition. Throughout the process, the healthcare team maintains clear communication with the patient, ensuring she is informed and supported during this critical juncture in her care.

Section 5

As the patient is transferred to the operating room for an emergency cesarean section, the healthcare team remains vigilant in monitoring her status. Despite the administration of magnesium sulfate, the patient begins to exhibit signs of respiratory depression, with her respiratory rate dropping to 8 breaths per minute. This prompts an immediate response from the anesthesiology team, who administer supplemental oxygen and prepare to intubate if necessary. The patient's oxygen saturation levels are closely monitored, hovering at 89%, which indicates the need for continuous respiratory support and careful titration of magnesium levels to avoid further respiratory compromise.

Concurrently, the obstetrics team performs a rapid reassessment of fetal status via ultrasound, which continues to show concerning signs of fetal distress, including reduced amniotic fluid volume and persistent bradycardia with heart rates dipping to 90 beats per minute. These findings underscore the urgency of the situation, emphasizing the need for expedited surgical intervention to prevent further fetal hypoxia and potential acidosis. The decision to proceed with the cesarean section is reaffirmed, as the benefits of immediate delivery outweigh the risks associated with maternal respiratory compromise.

Throughout the preparation, the patient remains conscious and oriented, albeit anxious, requiring reassurance and clear communication from the team. Her vital signs are closely monitored, with blood pressure remaining elevated at 175/110 mmHg despite ongoing antihypertensive therapy. The multidisciplinary team, including obstetricians, anesthesiologists, and nursing staff, collaborates seamlessly to ensure the patient's safety and optimize outcomes for both mother and child. As the surgery begins, the team's focus shifts to stabilizing the patient post-delivery and addressing any new complications that may arise in the immediate postpartum period.