A magnesium sulfate b antihypertensive medications c

a. Magnesium sulfate
b. Antihypertensive medications
c. Delivery of the fetus
d. Administration of acetylsalicylic acid (ASA) every day of the pregnancy
ANS: C
If the fetus is viable and near term, delivery is the only known definitive treatment for
preeclampsia. Magnesium sulfate is one of the medications used to treat but not to cure
preeclampsia. Antihypertensive medications are used to lower the dangerously elevated
blood pressures in preeclampsia and eclampsia. Low doses of ASA (81 mg) have been
administered to women at high risk for developing preeclampsia.
PTS:
OBJ:
1 DIF: Cognitive Level: Knowledge REF: p. 539
Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
11. Which clinical sign is not included in the symptoms of preeclampsia?
a. Hypertension
b. Edema
c. Proteinuria
d. Glycosuria

ANS: D
Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia.
Hypertension is usually the first sign noted. Edema occurs but is considered a non-
specific sign. Edema can lead to rapid weight gain. Proteinuria should be assessed
through a 24-hour UA.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 537 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
12. A nurse is assessing a woman receiving magnesium sulfate. The nurse assesses her deep
tendon reflexes at 0 and 1+. What action by the nurse is best?
a. Hold the magnesium sulfate.
b. Ask the provider to order a 24-hour UA.
c. Assess the woman’s temperature.
d. Take the woman’s blood pressure.
ANS: A
Absent or hypoactive deep tendon reflexes are indicative of magnesium sulfate toxicity. The
nurse should hold the magnesium and notify the provider. There is no need for a 24- hour
UA at this point. Temperature changes are not related to magnesium. Blood pressure can be
assessed, but that is not the priority.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 542 OBJ: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
13. The labor of a pregnant woman with preeclampsia is going to be induced. The nurse
reviews the woman’s latest laboratory test findings, which reveal a low platelet count, an
elevated aspartate transaminase (AST) level, and a falling hematocrit. What action by the
nurse is most important?
a. Palpate the woman’s abdomen for tenderness.
b. Document findings and begin the Pitocin infusion.
c. Instruct the woman to ask for help getting out of bed.
d. Assess the woman’s drinking history.
ANS: C
This woman has HELLP syndrome, with is characterized by low platelet counts and hepatic
dysfunction. She is at risk for bleeding, so the nurse instructs her to call for assistance in
getting in and out of bed. The nurse does not palpate the abdomen even though the woman may
complain of abdominal pain because of possible rupture of a subcapsular hematoma. The
findings should be documented but the nurse should intervene based on the abnormal findings.