A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago.
Which of the following instructions should the nurse include?
“You can stop taking your blood pressure medication now that you have delivered your baby.”
“You should avoid breastfeeding your baby until your blood pressure is normal.”
“You should report any headache or visual changes to your doctor immediately.”
“You should limit your fluid intake to prevent fluid overload.”
The Correct Answer is C
The nurse should instruct the client to report any headache or visual changes to the doctor immediately, as these are signs of worsening preeclampsia that can lead to serious complications such as stroke, eclampsia, or HELLP syndrome. Preeclampsia can persist or even begin after delivery, most often within 48 hours, so the client should monitor her blood pressure and symptoms until they resolve.
Choice A is wrong because the client should not stop taking her blood pressure medication without consulting her doctor. Blood pressure medication helps lower the blood pressure and protects the organs from damage. The blood pressure usually returns to normal within several days to weeks after delivery, but some clients may need medication for longer.
Choice B is wrong because the client should not avoid breastfeeding her baby unless there is a medical reason to do so. Breastfeeding has many benefits for both the mother and the baby, and does not affect the blood pressure or the preeclampsia.
Choice D is wrong because the client should not limit her fluid intake to prevent fluid overload. Fluid overload is not a common complication of preeclampsia, and limiting fluids can cause dehydration and affect the milk supply for breastfeeding.
The client should drink enough fluids to stay hydrated and follow a balanced diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Absence of seizures indicates a therapeutic response to magnesium sulfate therapy for a client with eclampsia.Magnesium sulfate is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Magnesium sulfate may act as a vasodilator, an anticonvulsant, and a protector of the blood-brain barrier.
Choice B is wrong because a decrease in urine output may indicate renal impairment, which is a complication of preeclampsia and eclampsia.
Choice C is wrong because an increase in deep tendon reflexes may indicate hyperreflexia, which is a sign of increased neuromuscular irritability and a risk factor for seizures.
Choice D is wrong because an increase in respiratory rate may indicate respiratory distress, which can be caused by pulmonary edema, another complication of preeclampsia and eclampsia.
Normal ranges for urine output are 0.5 to 1 mL/kg/hour, for deep tendon reflexes are 1+ to 2+, and for respiratory rate are 12 to 20 breaths per minute.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.