A nurse is caring for a patient in labor with a diagnosis of mild pre-eclampsia and suspected HELLP syndrome. The patient is receiving magnesium sulfate therapy. Which of the following assessments should the nurse prioritize to ensure maternal safety?

B) Assess deep tendon reflexes and respiratory rate

A) Monitor fetal heart rate for variability and decelerations

B) Assess deep tendon reflexes and respiratory rate

C) Check for cervical dilation and effacement

D) Measure urine output every hour

A patient in labor with a history of mild pre-eclampsia is diagnosed with HELLP syndrome. The healthcare team has initiated magnesium sulfate therapy. Which nursing intervention is the most critical to prevent complications associated with this treatment?

A) Monitor deep tendon reflexes regularly

B) Administer calcium gluconate prophylactically

C) Encourage the patient to ambulate frequently

D) Increase fluid intake to promote diuresis

A nurse is caring for a patient with pre-eclampsia who is receiving magnesium sulfate therapy. The patient's deep tendon reflexes are diminished, and her blood pressure remains elevated at 162/104 mmHg. Which of the following actions should the nurse take next?

B) Notify the healthcare provider of potential magnesium toxicity and prepare for calcium gluconate administration.

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

B) Notify the healthcare provider of potential magnesium toxicity and prepare for calcium gluconate administration.

C) Discontinue magnesium sulfate and start an antihypertensive medication immediately.

D) Continue to monitor the patient closely and reassess blood pressure in 30 minutes.

A patient in labor with pre-eclampsia is receiving magnesium sulfate for seizure prophylaxis. The nurse notes diminished deep tendon reflexes and a blood pressure of 162/104 mmHg. The fetal heart rate shows variable decelerations. What should be the nurse's priority intervention?

D) Reassess the patient's deep tendon reflexes and respiratory status to monitor for magnesium toxicity.

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

B) Administer a bolus of normal saline to improve fetal circulation.

C) Prepare the patient for possible cesarean delivery due to fetal distress.

D) Reassess the patient's deep tendon reflexes and respiratory status to monitor for magnesium toxicity.

A patient with pre-eclampsia is showing signs of progression towards HELLP syndrome with worsening headache, high blood pressure, and variable fetal heart rate decelerations. What is the priority nursing intervention at this time?

B) Prepare the patient for an emergency cesarean section

A) Increase the dose of oxytocin to speed up labor

B) Prepare the patient for an emergency cesarean section

C) Administer antihypertensive medication as prescribed

D) Increase the magnesium sulfate infusion rate to prevent seizures

A patient with severe pre-eclampsia is showing signs of HELLP syndrome and mild renal impairment. Her current blood pressure is 164/106 mmHg, and she is experiencing a worsening headache. Which nursing intervention should be prioritized to prevent further complications?

B) Administer hydralazine as ordered to help lower the blood pressure.

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

B) Administer hydralazine as ordered to help lower the blood pressure.

C) Prepare the patient for an immediate cesarean section to address fetal distress.

D) Provide the patient with acetaminophen for headache relief and reassess in 30 minutes.

A 32-year-old pregnant patient at 36 weeks gestation presents with escalating symptoms of pre-eclampsia, including severe hypertension, worsening headache, and visual disturbances. Fetal monitoring shows late decelerations, and a biophysical profile reveals a score of 4/10 with oligohydramnios. The decision has been made to proceed with an emergency cesarean section. What is the priority nursing action prior to the surgical procedure?

A) Administer magnesium sulfate to prevent seizures

B) Increase the rate of IV fluids to improve fetal perfusion

C) Obtain informed consent for the cesarean section

D) Notify the neonatal team to prepare for potential resuscitation

A pregnant patient with severe pre-eclampsia is being prepared for an emergency cesarean section due to worsening maternal symptoms and fetal distress. Which nursing intervention is the priority at this time?

A) Administer magnesium sulfate to prevent seizures.

B) Monitor maternal blood pressure every 15 minutes.

C) Prepare the surgical site for the cesarean section.

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

A patient undergoing an emergency cesarean section is experiencing severe hypertension, hyperactive reflexes, and epigastric pain. Her platelet count is 90,000/uL, and liver enzymes are elevated. Which nursing intervention should take priority to prevent further complications in this clinical scenario?

B) Initiate magnesium sulfate infusion to prevent seizure activity.

A) Administer antihypertensive medications to manage the elevated blood pressure.

B) Initiate magnesium sulfate infusion to prevent seizure activity.

C) Prepare for blood transfusion due to low platelet count.

D) Monitor fetal heart rate continuously to assess for fetal distress.

A patient undergoing an emergency cesarean section is experiencing severe hypertension, hyperactive reflexes, and epigastric pain, with laboratory findings indicating thrombocytopenia and elevated liver enzymes. Which immediate nursing intervention is the most critical to prioritize for this patient?

B) Initiate magnesium sulfate infusion to prevent seizure activity.

A) Administer antihypertensive medication to manage blood pressure.

B) Initiate magnesium sulfate infusion to prevent seizure activity.

C) Prepare for possible blood transfusion due to low platelet count.

D) Monitor fetal heart rate continuously to assess for distress.

labor and delivery - Nursing Case Study

Pathophysiology

• Primary mechanism: Hormonal changes initiate labor, with increased estrogen and decreased progesterone stimulating uterine contractions. Oxytocin release from the posterior pituitary gland enhances these contractions, promoting cervical dilation and effacement.

• Secondary mechanism: Mechanical stretch from the growing fetus and amniotic fluid contributes to the activation of the myometrium and production of prostaglandins, which further amplify uterine contractility and softening of the cervix.

• Key complication: Inadequate uterine contractions or dysfunctional labor patterns can lead to prolonged labor, increasing the risk of maternal and fetal distress, necessitating interventions such as oxytocin administration or cesarean delivery to ensure safe outcomes.

Patient Profile

Demographics:

28-year-old female, elementary school teacher

History:

• Key past medical history: Gestational diabetes managed with diet, mild pre-eclampsia in current pregnancy

• Current medications: Prenatal vitamins, insulin (for gestational diabetes)

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Intense lower abdominal pain and increased blood pressure

• Key symptoms: Severe headache, blurred vision, edema in hands and feet

• Vital signs: Blood pressure 155/95 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F

Section 1

As the labor progresses, the healthcare team conducts an initial assessment to further evaluate the patient's condition. The nurse notices that the patient appears increasingly uncomfortable, frequently adjusting her position to alleviate the intense lower abdominal pain. On physical examination, the uterus is palpated and found to be firm and tender, with contractions occurring at irregular intervals. Despite the ongoing contractions, the cervix is only dilated to 3 cm, indicating a potential for dysfunctional labor patterns. The fetal heart rate is monitored continuously, showing a baseline of 150 bpm with occasional variable decelerations, suggesting possible fetal distress due to prolonged labor.

Given the patient's history of mild pre-eclampsia, her blood pressure remains a concern, consistently reading around 160/100 mmHg. The severe headache and blurred vision further raise suspicion of worsening pre-eclampsia. Laboratory tests are ordered urgently, revealing elevated liver enzymes and low platelet count, indicative of HELLP syndrome—a severe form of pre-eclampsia that could complicate labor and delivery. Urine tests show significant proteinuria, corroborating the diagnosis.

In response to these findings, the obstetrics team decides to initiate magnesium sulfate therapy to prevent seizures and manage the symptoms of pre-eclampsia. Additionally, oxytocin is considered to augment labor due to the inadequate contractions. The patient is closely monitored in the labor and delivery unit, with frequent assessments of maternal and fetal well-being. The interdisciplinary team discusses the possibility of a cesarean delivery if labor does not progress satisfactorily or if the maternal or fetal condition deteriorates further. These decisions require careful consideration of the risks and benefits, emphasizing the importance of vigilant monitoring and timely intervention.

Section 2

As the patient continues to labor under close observation, her response to magnesium sulfate therapy is carefully monitored. Initial assessments reveal that her deep tendon reflexes are diminished, an expected side effect of the magnesium therapy, but warranting vigilant monitoring to prevent magnesium toxicity. Despite this intervention, her blood pressure remains elevated at 162/104 mmHg, and her headache persists, indicating the ongoing challenge of managing her pre-eclampsia. The patient's discomfort intensifies as contractions remain irregular, and cervical dilation progresses slowly, now at 4 cm after several hours.

The fetal heart rate pattern becomes a focal point of concern; while the baseline remains around 150 bpm, variable decelerations become more frequent and pronounced. These are suggestive of potential umbilical cord compression, likely exacerbated by the uterine tenderness and irregular contractions. The decision to administer oxytocin has been met with caution given the risk of further stressing the fetus and the already present uterine irritability.

The team re-evaluates the situation, discussing the likelihood of needing a cesarean delivery if the fetal distress does not resolve or if labor fails to progress. A repeat complete blood count and comprehensive metabolic panel are ordered to assess any changes in maternal status, particularly focusing on potential worsening of the HELLP syndrome. The interdisciplinary team prepares for possible surgical intervention, ensuring that the operating room is on standby and that the necessary personnel and resources are available. This proactive approach underscores the importance of balancing maternal and fetal safety with the progression of labor, emphasizing the need for ongoing comprehensive assessment and timely decision-making.

Section 3

As the situation unfolds, the new diagnostic results provide crucial insights into the patient's condition. The repeat complete blood count reveals a hemoglobin level of 10.5 g/dL, platelet count of 90,000/mm³, and elevated liver enzymes (AST 85 U/L, ALT 92 U/L), indicating a progression towards HELLP syndrome. The comprehensive metabolic panel shows a serum creatinine of 1.4 mg/dL, suggesting mild renal impairment, likely aggravated by the ongoing hypertensive state. These findings necessitate immediate attention, as they reflect deteriorating maternal status and underscore the severity of her pre-eclampsia.

In response to these results, the healthcare team intensifies their monitoring and management strategies. The magnesium sulfate infusion is carefully titrated to maintain therapeutic levels while minimizing the risk of toxicity. The patient's reflexes and respiratory status are assessed frequently to ensure safety. In parallel, the team decides to administer a low-dose oxytocin infusion cautiously, aiming to enhance cervical dilation and promote more effective contractions while closely watching the fetal heart rate pattern for any signs of distress.

Despite these interventions, the patient's condition continues to challenge the clinical team. Her headache becomes more pronounced, and blood pressure remains difficult to control, now reading at 164/106 mmHg. The fetal heart rate monitoring persists with variable decelerations, prompting the team to discuss the possibility of a cesarean section more seriously. The decision-making process highlights the complexity of balancing the risks and benefits of continued labor versus surgical delivery, with the ultimate goal of optimizing outcomes for both mother and child. The team remains vigilant, ready to act swiftly should the patient's condition worsen or fetal distress become evident.

Section 4

As the clinical team continues to monitor the patient closely, new complications emerge that require immediate attention. The patient's blood pressure remains elevated despite the administration of antihypertensive medications, with readings now fluctuating between 168/110 mmHg and 170/112 mmHg. Her headache intensifies, and she begins to experience visual disturbances, including seeing spots and blurring, further suggesting escalating pre-eclampsia severity. These symptoms prompt the healthcare team to perform a fundoscopic examination, revealing retinal changes consistent with hypertensive retinopathy.

Simultaneously, the fetal heart rate monitoring shows increased variability in decelerations, now categorized as late decelerations, indicating potential fetal compromise. The biophysical profile (BPP) score has decreased to 4/10, emphasizing the urgency of reassessing the current plan of care. A repeat ultrasonography confirms oligohydramnios, with amniotic fluid index (AFI) reduced to 3 cm, further complicating the clinical picture.

Given the worsening maternal symptoms and signs of fetal distress, the team deliberates the need for immediate surgical intervention. The decision is made to proceed with an emergency cesarean section to prevent further deterioration of both maternal and fetal conditions. The operating room is prepped swiftly, with anesthesia and neonatal teams on standby. As the patient is prepared for surgery, the team remains acutely aware of the delicate balance required to stabilize her condition while ensuring a safe delivery for the baby.

Section 5

As the surgical team prepares for the emergency cesarean section, the patient is closely monitored for any additional changes in her condition. Despite the team's efforts to manage her hypertension, her blood pressure continues to rise, now peaking at 175/115 mmHg. The patient's reflexes become hyperactive, with a 4+ patellar reflex and the presence of clonus, indicating potential progression towards eclampsia. Her headache worsens, and she reports a new onset of epigastric pain, raising concerns about possible liver involvement or imminent seizure activity.

In the operating room, the anesthesia team faces the challenge of managing her escalating hypertension while ensuring adequate pain control and maternal safety. A magnesium sulfate infusion is initiated to prevent seizures, with close monitoring of her serum magnesium levels to avoid toxicity. Her platelet count, previously borderline, has now dropped to 90,000/uL, raising concerns about coagulopathy and the potential for disseminated intravascular coagulation (DIC). Liver function tests reveal elevated liver enzymes, further complicating the clinical picture and suggesting HELLP syndrome.

As the cesarean section proceeds, the fetal heart rate reveals persistent late decelerations, underscoring the urgency of delivering the baby. The neonatology team remains vigilant, ready to provide immediate care for the newborn, anticipating potential complications such as respiratory distress or the need for resuscitation. The surgical team maintains a heightened awareness of the possibility of intraoperative bleeding due to the patient's low platelet count, preparing for potential interventions to manage any hemorrhagic complications. This complex interplay of maternal and fetal conditions requires precise coordination and rapid decision-making to ensure the best possible outcomes for both mother and child.