A pregnant patient is diagnosed with worsening gestational hypertension and is being monitored for possible development of preeclampsia. Which of the following clinical findings would most strongly indicate the progression to HELLP syndrome?

A) Proteinuria of 400 mg in a 24-hour urine collection

D) Fetal ultrasound showing increased uterine artery resistance

A pregnant patient at 32 weeks of gestation presents with proteinuria, mild thrombocytopenia, and elevated liver enzymes. Doppler studies reveal increased resistance in the uterine arteries. Based on these findings, which nursing intervention is most important to prioritize for this patient?

B) Monitor blood pressure closely and administer antihypertensives as prescribed

A) Educate the patient on the importance of bed rest to improve placental perfusion

B) Monitor blood pressure closely and administer antihypertensives as prescribed

C) Schedule frequent fetal biophysical profiles to assess fetal well-being

D) Prepare for immediate delivery due to the risk of HELLP syndrome

A patient in the obstetrics triage unit presents with persistent headaches and new-onset visual disturbances. Her blood pressure is 160/105 mmHg, platelets are 115,000/mm³, ALT is 75 U/L, AST is 85 U/L, and 24-hour urine protein is 600 mg. Which nursing intervention is the priority in managing this patient's condition?

A) Administer intravenous magnesium sulfate as prescribed to prevent seizures.

B) Initiate bed rest to reduce the risk of further complications.

C) Educate the patient on dietary changes to manage blood pressure.

D) Prepare the patient for immediate delivery to address fetal distress.

A pregnant patient at 34 weeks gestation presents with persistent headaches, visual disturbances, and elevated blood pressure of 160/105 mmHg. Laboratory findings indicate decreased platelet count, elevated liver enzymes, and increased proteinuria. Which nursing intervention is most critical to prioritize in this scenario?

A) Administer intravenous magnesium sulfate as ordered.

B) Encourage the patient to ambulate to promote circulation.

C) Educate the patient on maintaining a low-sodium diet.

D) Prepare the patient for an elective cesarean section.

A patient receiving magnesium sulfate for seizure prophylaxis in severe preeclampsia begins to show signs of magnesium toxicity. Which nursing intervention should take priority to ensure patient safety?

C) Administer calcium gluconate as prescribed.

A) Decrease the rate of the magnesium sulfate infusion.

B) Monitor the patient's blood pressure every 15 minutes.

C) Administer calcium gluconate as prescribed.

D) Prepare for immediate delivery of the fetus.

A pregnant patient receiving magnesium sulfate infusion for seizure prophylaxis in preeclampsia develops magnesium toxicity. What is the most appropriate initial nursing action to address the patient's low respiratory rate and decreased deep tendon reflexes?

B) Administer calcium gluconate as prescribed

A) Decrease the magnesium sulfate infusion rate

B) Administer calcium gluconate as prescribed

C) Increase the patient's oxygen flow rate

D) Reassess the patient's vital signs in 15 minutes

A patient undergoing labor induction is experiencing increased headache severity, visual disturbances, and elevated blood pressure. Despite magnesium sulfate cessation, her blood pressure remains high, and laboratory findings indicate renal involvement. Which nursing intervention is most critical to prioritize at this time?

B) Prepare the patient for an emergent cesarean section due to severe preeclampsia

A) Administer additional doses of magnesium sulfate to prevent seizures

B) Prepare the patient for an emergent cesarean section due to severe preeclampsia

C) Increase the frequency of maternal and fetal monitoring

D) Administer a diuretic to reduce fluid overload

A patient in labor is being monitored for preeclampsia with severe features. Which nursing intervention is most appropriate when the patient reports increased headache severity and visual disturbances?

B) Reassess the patient's blood pressure and notify the healthcare provider.

A) Administer a bolus of magnesium sulfate.

B) Reassess the patient's blood pressure and notify the healthcare provider.

C) Increase the patient's fluid intake to ensure adequate hydration.

D) Encourage the patient to rest in a supine position to alleviate symptoms.

A patient with a history of preeclampsia is experiencing sudden changes in neurological status, including confusion and disorientation, along with elevated blood pressure, severe headache, and visual disturbances. What is the most appropriate initial nursing intervention to address the risk of eclampsia in this patient?

B) Initiate seizure precautions and administer magnesium sulfate.

A) Administer a bolus of intravenous fluids.

B) Initiate seizure precautions and administer magnesium sulfate.

C) Elevate the head of the bed to reduce intracranial pressure.

D) Administer high-dose antihypertensive medication.

A pregnant patient with severe preeclampsia is exhibiting confusion, disorientation, and clonus, with decreased urine output. Which immediate nursing intervention is the most critical to stabilize her condition?

B) Administer magnesium sulfate as ordered to prevent seizure activity.

A) Increase the rate of intravenous fluids to improve renal perfusion.

B) Administer magnesium sulfate as ordered to prevent seizure activity.

C) Position the patient in a high Fowler's position to alleviate headache symptoms.

D) Prepare the patient for an emergent cesarean section to expedite delivery.

gestational hypertention - Nursing Case Study

Pathophysiology

• Primary mechanism: Placental dysfunction — Inadequate trophoblastic invasion leads to poor remodeling of spiral arteries, causing placental ischemia and release of antiangiogenic factors into maternal circulation, increasing blood pressure.

• Secondary mechanism: Endothelial dysfunction — The presence of these circulating factors triggers systemic endothelial cell activation and dysfunction in the mother, resulting in vasoconstriction, increased vascular resistance, and further elevation of blood pressure.

• Key complication: Organ damage — Sustained hypertension can lead to end-organ damage, particularly affecting the kidneys, liver, and brain, which may progress to preeclampsia if not managed effectively.

Patient Profile

Demographics:

32-year-old female, office manager

History:

• Key past medical history: Previous pregnancy with no complications, borderline hypertension prior to pregnancy

• Current medications: Prenatal vitamins, labetalol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headaches and swelling in hands and feet

• Key symptoms: Elevated blood pressure, headaches, visual disturbances, mild proteinuria

• Vital signs: Blood pressure 150/95 mmHg, heart rate 90 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F

Section 1

New Diagnostic Results:

Following the initial assessment, further diagnostic evaluations were conducted to better understand the patient's condition. A 24-hour urine collection was performed, revealing a proteinuria level of 400 mg, confirming the suspicion of worsening gestational hypertension. Additionally, a complete blood count (CBC) showed a mild thrombocytopenia with platelet levels at 130,000/mm³, suggesting possible development towards preeclampsia. Liver function tests indicated mildly elevated liver enzymes, with ALT at 55 U/L and AST at 62 U/L, pointing to potential hepatic involvement.

Ultrasound examination of the fetus showed normal growth parameters and amniotic fluid levels, which was reassuring for fetal health at this stage. However, Doppler studies of the uterine arteries revealed increased resistance, consistent with poor placental perfusion. This finding corroborates the primary mechanism of placental dysfunction contributing to the maternal hypertensive state.

These results prompted a multidisciplinary team discussion to reassess the management plan. Given the progression of symptoms and laboratory findings, the decision was made to closely monitor the patient for any further signs of preeclampsia or HELLP syndrome. Adjustments to her antihypertensive regimen were considered to better control her blood pressure, while ensuring fetal safety. The care team emphasized the importance of regular follow-ups and patient education to recognize warning signs that would necessitate immediate medical attention. This proactive approach aims to mitigate the risk of severe complications while maintaining maternal and fetal well-being.

Section 2

Change in Patient Status:

A few days after the initial reassessment, the patient presented to the obstetrics triage unit with complaints of persistent headaches and new-onset visual disturbances, including seeing spots and flashes of light. Upon examination, her blood pressure had risen to 160/105 mmHg, indicating poor control despite the recent adjustments to her antihypertensive regimen. These symptoms, coupled with her elevated blood pressure, raised significant concerns about the progression toward severe preeclampsia.

The medical team promptly ordered repeat laboratory tests to evaluate any further changes in her condition. The CBC now showed a further decrease in platelets to 115,000/mm³, and liver function tests revealed a continued upward trend in enzyme levels, with ALT at 75 U/L and AST at 85 U/L. These findings suggested worsening hepatic involvement and potential progression to HELLP syndrome. The 24-hour urine protein increased to 600 mg, further substantiating the diagnosis of advancing preeclampsia.

In response to these developments, the healthcare team initiated intravenous magnesium sulfate to prevent seizures and adjusted her antihypertensive medications for more aggressive blood pressure control. Fetal monitoring was intensified to ensure the ongoing well-being of the fetus, given the maternal complications. The patient was counseled on the necessity of potential early delivery if her condition continued to deteriorate, emphasizing the critical balance between prolonging the pregnancy for fetal development and ensuring maternal safety. This change in status necessitated a vigilant approach to anticipate and manage potential acute complications effectively.

Section 3

A few hours after initiating the magnesium sulfate infusion, the patient began to exhibit signs of magnesium toxicity, including decreased deep tendon reflexes and respiratory rate dropping to 10 breaths per minute. Her serum magnesium level was measured at 9.0 mg/dL, significantly higher than the therapeutic range of 4.8-8.4 mg/dL. The healthcare team immediately responded by halting the magnesium sulfate infusion and administering calcium gluconate as an antidote to counteract the adverse effects. Concurrently, the patient's blood pressure remained elevated, with readings fluctuating between 155/100 mmHg and 165/110 mmHg, despite the adjusted antihypertensive regimen.

In light of these developments, a multidisciplinary team meeting was convened to reassess the management plan. The team acknowledged the complexity of balancing adequate seizure prophylaxis with the risk of magnesium toxicity and the ongoing challenge of blood pressure control. Considering the worsening maternal symptoms and the potential risks to both mother and fetus, the decision was made to expedite delivery. A course of corticosteroids was administered to enhance fetal lung maturity, given the likelihood of preterm birth.

Fetal monitoring showed reactive non-stress tests, suggesting the fetus was coping well despite the maternal complications. However, the ongoing maternal instability necessitated a shift in focus towards optimizing outcomes through timely delivery. The patient was prepared for an induction of labor, with continuous monitoring and support in place to manage any emergent complications. This plan underscored the importance of dynamic clinical reasoning in adapting to rapidly changing clinical scenarios, aiming to balance maternal and fetal health priorities effectively.

Section 4

As labor induction commenced, the patient's condition was closely monitored, with particular attention paid to her vital signs and neurological status. Despite the cessation of magnesium sulfate, the patient's blood pressure remained notably high, with readings persisting around 160/105 mmHg, necessitating further titration of her antihypertensive medications. Her deep tendon reflexes gradually returned to normal, and her respiratory rate improved to 14 breaths per minute, indicating a positive response to the calcium gluconate administration. Continuous fetal monitoring showed stable heart rate patterns, providing reassurance of fetal well-being despite the maternal hypertension.

Shortly after the initiation of induction, the patient began to report increased headache severity and visual disturbances, including seeing flashing lights. These symptoms raised concerns about the potential development of preeclampsia with severe features, prompting the healthcare team to conduct further diagnostic evaluations. Laboratory results revealed an elevated serum creatinine level of 1.3 mg/dL, up from her baseline of 0.8 mg/dL, and new-onset proteinuria with a 24-hour urine collection yielding 400 mg of protein. These findings indicated renal involvement and confirmed the progression to severe preeclampsia.

In response to the worsening clinical picture, the decision was made to expedite the delivery process further. The team prepared for the possibility of an emergent cesarean section if labor progression did not proceed swiftly or if maternal or fetal distress was detected. This scenario highlighted the ongoing challenge of managing complex and evolving obstetric emergencies, emphasizing the critical role of timely and informed clinical decision-making to optimize outcomes for both mother and fetus.

Section 5

As the healthcare team continued to monitor the patient closely, they observed a sudden change in her neurological status. The patient began to exhibit confusion and disorientation, with difficulty following simple commands, which was a significant deviation from her previous alert and oriented state. Her blood pressure remained elevated, despite the adjusted antihypertensive regimen, with readings now fluctuating between 165/110 mmHg and 170/112 mmHg. This neurological change, coupled with her severe headache and visual disturbances, raised the concern for impending eclampsia or cerebral edema.

In response to these alarming signs, a stat head CT scan was ordered to rule out any intracranial bleeding or edema. Simultaneously, the patient was placed on seizure precautions, and magnesium sulfate therapy was promptly restarted to prevent seizure activity. The team remained vigilant, ready to intervene at the first sign of seizure or further deterioration in her neurological status.

Despite these proactive measures, the patient's condition continued to worsen. She developed clonus, a new and concerning finding, indicating heightened neuromuscular irritability. Her urine output also decreased significantly to 15 mL/hour, suggesting worsening renal impairment and further emphasizing the severity of her condition. These developments underscored the urgency of expediting delivery, prompting the decision to proceed with an emergent cesarean section to stabilize the patient and reduce the risk of further complications for both her and the fetus. The team prepared for surgery, ensuring that all necessary resources and personnel were ready to provide comprehensive care during this critical period.