A nurse is educating a client with mild pre-eclampsia about the signs and symptoms that she should report to her health care provider.
Which of the following should the nurse include? (Select all that apply.)
Sudden weight gain
Swelling of the face and hands
Epigastric pain
Decreased fetal movement
Vaginal bleeding
Correct Answer : C,D
The correct answer is choice C and D. Epigastric pain and decreased fetal movement are signs of severe pre-eclampsia that indicate damage to the liver and placenta respectively. These symptoms should be reported to the health care provider immediately as they may lead to serious complications such as eclampsia, HELLP syndrome, placental abruption or fetal growth restriction.
Choice A is wrong because sudden weight gain is a common symptom of mild pre-eclampsia that does not necessarily require immediate attention. However, it should be monitored regularly along with blood pressure and urine protein levels.
Choice B is wrong because swelling of the face and hands is also a common symptom of mild pre-eclampsia that does not indicate severe organ damage. It may be caused by fluid retention or edema.
Choice E is wrong because vaginal bleeding is not a typical symptom of pre-eclampsia. It may be a sign of other pregnancy complications such as placenta previa, placental abruption or cervical infection.
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Correct Answer is C
Explanation
The client should not resume normal activities as soon as she gets home because she is still at risk for complications from preeclampsia.She should rest as directed by her healthcare provider and avoid strenuous activities that may increase her blood pressure.
Choice A is wrong because monitoring blood pressure at home is a recommended practice for clients who had preeclampsia.It can help detect any signs of worsening hypertension or organ damage.
Choice B is wrong because reporting any headache, vision changes, or abdominal pain to the doctor is a crucial step to prevent serious complications from preeclampsia.These symptoms may indicate damage to the brain, eyes, or liver and require immediate medical attention.
Choice D is wrong because continuing to take prenatal vitamins and iron supplements is beneficial for the client’s recovery and health.Prenatal vitamins can provide essential nutrients that may be lacking in the diet, and iron supplements can prevent or treat anemia that may result from blood loss during delivery.
Correct Answer is A
Explanation
A. Urinary output of 25 mL/hour.This indicates magnesium toxicity and requires immediate intervention because it means the kidneys are not functioning properly and magnesium is not being excreted.Magnesium toxicity can cause life-threatening complications such as respiratory depression, cardiac arrest, and coma.
B. Respiratory rate of 14 breaths/minute is normal and does not indicate magnesium toxicity.A respiratory rate of less than 12 breaths/minute or more than 20 breaths/minute would be abnormal and require further assessment.
C. Deep tendon reflexes 1+ are normal and do not indicate magnesium toxicity.A loss of deep tendon reflexes or clonus would indicate magnesium toxicity and require immediate intervention.
D. Serum magnesium level of 6 mg/dL is within the therapeutic range for preeclampsia and does not indicate magnesium toxicity.
The therapeutic range for preeclampsia is 4 to 7 mg/dL.A serum magnesium level of more than 8 mg/dL would indicate magnesium toxicity and require immediate intervention.
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