A nurse is teaching a client who is at risk for developing preeclampsia.
Which of the following statements by the client indicates an understanding of the teaching?
“I should avoid foods that are high in sodium.”
“I should lie on my left side for at least 2 hours a day.”
“I should check my blood pressure at home every day.”
“I should take a baby aspirin every day as prescribed.”
The Correct Answer is D
“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%. If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).
Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia. Sodium intake does not affect blood pressure in pregnancy.
Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia. However, lying on your left side may help improve blood flow to your placenta and your baby.
Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia. However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.
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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.
Correct Answer is A
Explanation
Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.
Choice B is wrong because magnesium sulfate does not affect blood glucose levels.
There is no need to monitor the client’s blood glucose level every 4 hours.
Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.
A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.
Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.
Increasing the infusion rate can increase the risk of toxicity.
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