A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV.

Which of the following adverse effects should the nurse monitor for?

Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.

This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.

Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.

Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.

Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.

The client has no seizures or eclampsia.This outcome would indicate that the magnesium sulfate therapy is successful because magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.

Some additional information for the other choices are:

• Choice B. The client delivers a healthy baby vaginally.

This outcome is desirable but not directly related to the effectiveness of magnesium sulfate therapy.Magnesium sulfate can help prolong a pregnancy for up to two days to allow drugs that speed up the baby’s lung development to be administered, but it does not guarantee a vaginal delivery or a healthy baby.

• Choice C. The client has normal blood pressure and urine output.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate may help reduce blood pressure in some cases, but it is not the primary treatment for hypertension in preeclampsia.Other medications such as antihypertensives are usually prescribed for that purpose.Urine output should be monitored closely while receiving magnesium sulfate therapy, as a decrease may indicate toxicity or kidney impairment.Urine output should be at least 30 mL/hour while administering magnesium sulfate.

• Choice D. The client has improved liver function and platelet count.

This outcome is also desirable but not directly related to the effectiveness of magnesium sulfate therapy.

Magnesium sulfate does not affect liver function or platelet count in preeclampsia.These parameters may improve after delivery of the placenta, which is the main cause of preeclampsia.

Normal ranges for blood pressure, urine output, liver function and platelet count are:

• Blood pressure: less than 140/90 mm Hg

• Urine output: at least 30 mL/hour

• Liver function: AST and ALT less than 40 U/L, LDH less than 600 U/L, bilirubin less than 1.2 mg/dL

• Platelet count: 150,000 to 450,000 per microliter of blood