A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia.
Which of the following assessments should the nurse prioritize?
Respiratory rate and depth
Urine output and color
Blood pressure and heart rate
Level of consciousness and reflexes
The Correct Answer is D
The correct answer is choice D) Level of consciousness and reflexes. This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes. These are signs that the dose of magnesium sulfate should be reduced or stopped.
The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.
Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.
Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures. However, urine output should be monitored to ensure adequate hydration and renal function.
Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy. Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D) Swelling of the face, hands or feet.This is one of the signs and symptoms of gestational hypertension, which is high blood pressure that begins after 20 weeks of pregnancy and goes away after delivery.Gestational hypertension can lead to complications for both the mother and the baby, such as preeclampsia, which is a severe condition that causes protein in the urine and other problems.
Choice A) Severe headache is wrong because it is not a specific sign of gestational hypertension, but it can be a symptom of preeclampsia, which is a possible complication of gestational hypertension.
Choice B) Chest pain is wrong because it is not a common sign of gestational hypertension, but it can be a sign of a serious heart problem or a pulmonary embolism, which is a blood clot in the lungs.Chest pain during pregnancy should be evaluated by a doctor as soon as possible.
Choice C) Nausea or vomiting is wrong because it is not a typical sign of gestational hypertension, but it can be a symptom of preeclampsia or other conditions such as hyperemesis gravidarum, which is severe nausea and vomiting during pregnancy that can lead to dehydration and weight loss.
Normal blood pressure ranges for pregnant women are below 120/80 mm Hg.Gestational hypertension is diagnosed when the blood pressure is greater than or equal to 140/90 mm Hg after 20 weeks of pregnancy.
Correct Answer is C
Explanation
The correct answer is choice C) “I should report any dizziness or lightheadedness while taking this medication.” This is because labetalol can lower blood pressure and cause orthostatic hypotension, which can lead to falls and injuries.The patient should be advised to change positions slowly and monitor their blood pressure regularly while taking labetalol.
Choice A is wrong because labetalol can be taken with or without food.Taking it on an empty stomach does not affect its absorption or efficacy.
Choice B is wrong because labetalol does not affect potassium levels in the blood.Foods high in potassium are not contraindicated while taking this medication.
Choice D is wrong because swelling in the feet or hands can be a sign of worsening preeclampsia, which is a serious complication of hypertension in pregnancy.The patient should not stop taking labetalol without consulting their doctor, as this can cause rebound hypertension and endanger the mother and the fetus.The patient should seek medical attention if they experience swelling, headache, vision changes, abdominal pain, or reduced fetal movements.
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