A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands.

Which intervention is the priority for this client?

Administer magnesium sulfate as prescribed

Monitor the fetal heart rate and movement

Encourage bed rest in a left lateral position

Educate the client about the signs of eclampsia

Answer and Explanation

The Correct Answer is C

Encourage bed rest in a left lateral position.

This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus. The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.

Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.

Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.

Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia. Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.

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Correct Answer is A

Explanation

The most likely explanation for the client's findings of severe headache, blurred vision, hyperreflexia, and clonus in the context of severe pre-eclampsia is A. Cerebral edema.

Pre-eclampsia is a pregnancy-related condition characterized by high blood pressure (hypertension) and signs of organ damage, most commonly affecting the liver and kidneys. Severe pre-eclampsia can lead to complications such as eclampsia, which is characterized by seizures. The symptoms described by the client, including severe headache and blurred vision, are consistent with neurological manifestations associated with severe pre-eclampsia.

Hyperreflexia refers to an exaggerated reflex response, and clonus refers to rhythmic contractions of a muscle when it is passively stretched. Both hyperreflexia and clonus are indicative of central nervous system (CNS) hyperexcitability. Cerebral edema, which is the swelling of the brain due to fluid accumulation, can lead to increased intracranial pressure and neurological symptoms such as headache, vision changes, hyperreflexia, and clonus.

While other complications such as pulmonary edema (B), hemolysis (C), and thrombocytopenia (D) can occur in severe pre-eclampsia, they are not directly associated with the reported symptoms of severe headache, blurred vision, hyperreflexia, and clonus.

A. Report any headache that is not relieved by acetaminophen B. Expect some vaginal bleeding for up to 6 weeks postpartum C. Resume sexual activity as soon as you feel comfortable D. Drink at least 3 liters of fluid per day to prevent dehydration

Correct Answer is A

Explanation

Report any headache that is not relieved by acetaminophen.This is because a headache that persists despite taking pain medication can be a sign of increased blood pressure or brain swelling, which are serious complications of preeclampsia.

Choice B is wrong because some vaginal bleeding for up to 6 weeks postpartum is normal and expected for any woman who has given birth, regardless of whether she had preeclampsia or not.

Choice C is wrong because resuming sexual activity as soon as you feel comfortable is also a normal recommendation for any woman who has given birth, unless there are other medical reasons to avoid it.

Choice D is wrong because drinking at least 3 liters of fluid per day to prevent dehydration is not necessary for a woman who had preeclampsia.In fact, drinking too much fluid can worsen the swelling and fluid retention that are common in preeclampsia.

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A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands. Which intervention is the priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with severe pre-eclampsia who reports a severe headache and blurred vision. The nurse notes that the client has hyperreflexia with clonus. What is the most likely explanation for these findings?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who had preeclampsia and delivered a healthy baby at 38 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation