A nurse is reviewing the discharge instructions for a client who had severe preeclampsia and delivered her baby at 34 weeks of gestation by cesarean birth.
Which of the following statements by the client indicates an understanding of the teaching?
“I will need to take magnesium sulfate for another week.”
“I will have to monitor my blood pressure at home for a month.”
“I will have to avoid breastfeeding until my condition resolves.”
“I will have to use contraception for at least 6 months.”
The Correct Answer is B
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery. The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia. Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia. The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery.The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia.Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia.The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.
Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.
Normal ranges for the assessments are:
• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)
• Respiratory rate: 12 to 20 breaths per minute
• Urine output: at least 30 mL per hour
• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)
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