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?
Tachycardia
Hyperglycemia
Hypokalemia
Constipation
The Correct Answer is A
Hydralazine can cause tachycardia (fast heart rate) as a common side effect.
This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.
Choice B is wrong because hydralazine does not cause hyperglycemia (high blood sugar).
Hydralazine is not known to affect glucose metabolism or insulin secretion.
Choice C is wrong because hydralazine does not cause hypokalemia (low potassium levels).
Hydralazine is not a diuretic and does not increase potassium excretion.
Choice D is wrong because hydralazine does not cause constipation. Hydralazine can cause diarrhea as a common side effect, but not constipation.
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Correct Answer is D
Explanation
The client should have a follow-up visit with the provider in a week.This is because preeclampsia can persist or develop after delivery and requires close monitoring of blood pressure and signs of organ injury.
Choice A is wrong because vaginal bleeding is normal after delivery and does not indicate a complication of preeclampsia.
Choice B is wrong because the client should not stop taking blood pressure medication without consulting the provider.Preeclampsia can cause hypertension that may need treatment even after delivery.
Choice C is wrong because breastfeeding is not contraindicated for women with preeclampsia.Breastfeeding may even lower blood pressure and help the uterus contract.
Correct Answer is D
Explanation
Level of consciousness.
This is because magnesium sulfate, which is given to prevent seizures in severe preeclampsia, can cause respiratory depression and coma if the dose is too high.Therefore, the nurse should monitor the client’s level of consciousness and respiratory rate closely and report any signs of toxicity to the provider.
Choice A is wrong because hourly intake and output is not the most important assessment for this client.However, the nurse should monitor the urinary output as a sign of renal function and fluid balance and report any output less than 30 ml per hour.
Choice B is wrong because deep tendon reflexes are not the most important assessment for this client.However, the nurse should check the reflexes as a sign of neuromuscular irritability and report any hyperreflexia or clonus.
Choice C is wrong because lung sounds are not the most important assessment for this client.However, the nurse should auscultate the lungs as a sign of pulmonary edema and report any crackles or wheezes.
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