vSim - Olivia Jones Exam Questions And Verified Detailed Answers
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Which of the following entries on a patient's medical record are evidence of the
diagnosis of severe preeclampsia? (Select all that apply.)
a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
e) Negative urine ketones
f) Scotomata - ANSWER a) Oliguria
b) Blood pressure 182/116 mmHg
c) 3 lb (1.4 kg) weight gain in 1 week
d) Epigastric pain
f) Scotomata
All of the following findings, except one, negative ketones, confirm this diagnosis. The
urinary finding that would support this diagnosis is proteinuria.
For a client who is hospitalized with severe preeclampsia, which of the following must
be provided? (Select all that apply.)
a) Television to watch for diversion
b) Bed rest in a left lateral lying position
c) Frequent visitors for diversion and support
d) Seizure precautions
, e) Dim lighting
f) Minimal environmental stimulation - ANSWER b) Bed rest in left lateral lying position
d) Seizure precautions
e) Dimmed lights
f) Minimal environmental stimulation
The environment should be quiet, darkened, and relaxing. Seizure precautions must be
instituted for the possible onset of eclampsia. The changes in light intensity of a
television will increase CNS irritability. The frequent visitors will not provide a restful
environment for the patient.
What are the priorities of care if a pregnant woman experiences an eclamptic seizure?
(Select all that apply.)
a) Restrain the patient
b) Protect the patient from injury
c) Clear the airway
d) Insert a bite block to protect the tongue
e) Begin a cesarean birth immediately
f) Administer oxygen - ANSWER b) Protect the patient from injury
c) Clear the airway
f) Administer oxygen
The priorities are airway, oxygenation, and protection from injury. It is not helpful, and
may be harmful, to try to insert a bite block or to restrain a seizing patient. Labor is not
induced until seizures are well controlled.
Severely preeclamptic pregnant patients are at risk for the development of acute
pulmonary edema. What is the nurse's role in preventing this complication?
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