At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, “I felt like that when I had toxemia during my pregnancy. ” Admission assessment by the nurse reveals today’s weight 182 pounds, T 99. 1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear.
Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus. The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no contractions. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 station.
1. In reviewing Jennie’s history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder due to which risk factors?
- Age (15), molar pregnancy, history of preeclampsia in a previous pregnancy.
- Age (15), gravidity, familial history.
- Age (15), history of pounding headache, low socioeconomic status.
- Age (15), low socioeconomic status (SES), history of pedal edema.
2. To accurately assess this client’s condition, what information from the prenatal record is most important for the nurse to obtain?
- Pattern and number of prenatal visits.
- Prenatal blood pressure readings.
- Prepregnancy weight.
- Jennie’s Rh factor.
Assessing Deep Tendon Reflexes
To identify exaggerated reflexes (hyperreflexia) or diminished reflexes (hyporeflexia) You will need a reflex hammer to best assess both the brachial and the patellar reflexes. Support the woman’s arm and instruct her to let it go limp while it is being held so that the arm is totally relaxed and slightly flexed as you assess the brachial reflex. If you have difficulty identifying the correct tendon to tap, have the woman flex and extend her arm until you can feel it moving beneath your thumb.
Have her fully relax her arm after you identify the tendon. Place your thumb over the woman’s tendon, as illustrated, to allow you to feel as well as see the tendon response when the tendon is tapped. Strike the thumb with the small end of the triangular reflex hammer. The normal response is a slight flexion of the forearm. The patellar, or knee-jerk, reflex can be assessed with the woman in two positions, sitting or lying. When the woman is sitting, allow her lower legs to dangle freely to flex the knee and stretch the tendons.
If her patellar tendon is difficult to identify, have her flex, and extend her lower legs slightly until you palpate the tendon. Strike the tendon directly with the reflex hammer just below the patella. The patellar reflex is less reliable if the woman has had epidural analgesia, and upper extremity reflexes should be assessed. When the woman is supine, the weight of her leg must be supported to flex the knee and stretch the tendons. An accurate response requires that the limb be relaxed and the tendon partially stretched. Strike the partially stretched tendons just below the patella.
Slight extension of the leg or a brief twitch of the quadriceps muscle of the thigh is the expected response. For assessment of clonus, the woman’s lower leg should be supported, as illustrated, and the footwell dorsiflexed to stretch the tendon. Hold the flexion. If no clonus is present, no movement will be felt. When clonus (indicating hyperreflexia) is present, rapid rhythmic tapping motions of the foot are present. Deep Tendon Reflex Rating Scale* 0 Reflex absent +1 Reflex present, hypoactive +2 Normal reflex +3 Brisker than average reflex 4 Hyperactive reflex; clonus may also be present * The rating scales of some facilities omit the plus signs.
Pathophysiology of Preeclampsia
There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm. Function in organs such as the placenta, liver, brain, and kidneys can be depressed as much as 40 to 60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen.
The edema of preeclampsia is generalized. Virtually all organ systems are affected by this disease, and the mother and fetus suffer increasing risk as the disease progresses. Preeclampsia develops after 20 weeks gestation in a previously normotensive woman. Elevated blood pressure is frequently the first sign of preeclampsia. The client also develops proteinuria. While no longer considered a diagnostic measurement of preeclampsia, generalized edema of the face, hands, and abdomen that is not responsive to 12 hours of bed rest is often present.
Preeclampsia progresses along a continuum from mild to severe preeclampsia, HELLP syndrome, or eclampsia. A client may present to the labor unit anywhere along that continuum.
3. What is the pathophysiology responsible for Jennie’s complaint of a pounding headache and the elevated DTRs?
- Cerebral edema.
- Increased perfusion to the brain.
- Severe anxiety.
- Retinal arteriolar spasms. Jennie’s sister is very concerned about the swelling (edema) in her sister’s face and hands because it seems to be worsening rapidly.
She asks the nurse if the healthcare provider will prescribe some of “those water pills” (diuretics) to help get rid of the excess fluid.
4. Which response by the nurse is correct?
- “That is a very good idea. I will relay it to the healthcare provider when I call. “
- “I’m sorry, but it is not the family’s place to make suggestions about medical treatment. “
- “Let me explain to you about the effect of diuretics on pregnancy. “
- “Have you by any chance given your sister water pills that belong to someone else? “
Admission to the Labor and Delivery Unit At 0630 the nurse calls to report to the healthcare provider, who prescribes the following: admit to labor and delivery, bedrest with bathroom privileges (BRP), IV D5LR at 125 ml/hr, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital signs, and DTRs.
5. While awaiting the lab results, which nursing intervention has the highest priority?
- Teach Jennie the rationale for bedrest.
- Monitor Jennie for signs of dehydration.
- Educate the client about dietary restrictions.
- Observe Jennie for CNS changes.
6. Which technique is best for the nurse to use when evaluating Jennie’s blood pressure while she is on bedrest?
- Have Jennie lay supine and take the blood pressure on the left arm.
- Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.
- Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level.
- Have Jennie stand briefly and take the blood pressure on the right arm. The nurse performs a nonstress test to evaluate fetal well-being.
7. When performing a nonstress test, the nurse will be assessing for which parameters?
- Accelerations of the fetal heart rate in response to fetal movement.
- Late decelerations of the fetal heart rate in response to fetal movement.
- Accelerations of the fetal heart rate in response to uterine contractions.
- Late decelerations of the fetal heart rate in response to uterine contractions.
HELLP Syndrome At 0800, physical assessment and labs reveal the following: the client is still complaining of a headache but the epigastric pain has slightly decreased. While resting in a left lateral position, the vital signs are BP 146/94, P 75, R 18. Hyperreflexia continues with one beat of clonus. The baseline fetal heart rate is 140 with average long-term variability and no decelerations. Since completion of a reactive nonstress test, no further accelerations have occurred. Lab results include: hemoglobin – 13. 1 g/dl, hematocrit – 40. g/dl, platelets – 120,000 mm3, aspartate aminotransferase (AST) – slightly elevated, alanine aminotransferase (ALT) – normal for pregnancy, 0 burr cells on slide, clotting studies normal for pregnancy. The healthcare provider diagnoses Jennie with preeclampsia rather than HELLP syndrome, a variant of severe preeclampsia.
8. If Jennie had HELLP syndrome, which lab results would the nurse expect her to exhibit?
- Elevated hemoglobin and hematocrit (H&H) without burr cells, elevated liver enzymes, platelet count >150,000 mm3.
- Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count