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?
Report any headache that is not relieved by acetaminophen
Expect some vaginal bleeding for up to 6 weeks postpartum
Resume sexual activity as soon as you feel comfortable
Drink at least 3 liters of fluid per day to prevent dehydration
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
The correct answer is choice A, B, D and E. These are all signs of severe preeclampsia that indicate organ damage and require immediate medical attention.According to Mayo Clinic, preeclampsia is a complication of pregnancy that causes high blood pressure, protein in the urine, or other signs of organ damage after 20 weeks of gestation.
Choice A is correct because epigastric pain can indicate liver damage or bleeding in the abdomen due to preeclampsia.
Choice B is correct because blurred vision or light sensitivity can indicate brain damage or increased pressure in the skull due to preeclampsia.
Choice C is wrong because facial edema is a common symptom of normal pregnancy and does not necessarily indicate preeclampsia.
Choice D is correct because hyperreflexia can indicate nervous system damage or increased pressure in the skull due to preeclampsia.
Choice E is correct because oliguria can indicate kidney damage or decreased blood flow to the kidneys due to preeclampsia.
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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