(Select all that apply) A nurse is assessing a client who is 32 weeks pregnant and has a diagnosis of severe preeclampsia.
Which of the following findings should the nurse report to the provider immediately?
Epigastric pain
Blurred vision
Facial edema
Hyperreflexia
Oliguria
Correct Answer : A,B,D,E
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.
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Correct Answer is A
Explanation
The most likely explanation for the client's findings of severe headache, blurred vision, hyperreflexia, and clonus in the context of severe pre-eclampsia is A. Cerebral edema.
Pre-eclampsia is a pregnancy-related condition characterized by high blood pressure (hypertension) and signs of organ damage, most commonly affecting the liver and kidneys. Severe pre-eclampsia can lead to complications such as eclampsia, which is characterized by seizures. The symptoms described by the client, including severe headache and blurred vision, are consistent with neurological manifestations associated with severe pre-eclampsia.
Hyperreflexia refers to an exaggerated reflex response, and clonus refers to rhythmic contractions of a muscle when it is passively stretched. Both hyperreflexia and clonus are indicative of central nervous system (CNS) hyperexcitability. Cerebral edema, which is the swelling of the brain due to fluid accumulation, can lead to increased intracranial pressure and neurological symptoms such as headache, vision changes, hyperreflexia, and clonus.
While other complications such as pulmonary edema (B), hemolysis (C), and thrombocytopenia (D) can occur in severe pre-eclampsia, they are not directly associated with the reported symptoms of severe headache, blurred vision, hyperreflexia, and clonus.
Pre-eclampsia is a pregnancy-related condition characterized by high blood pressure (hypertension) and signs of organ damage, most commonly affecting the liver and kidneys. Severe pre-eclampsia can lead to complications such as eclampsia, which is characterized by seizures. The symptoms described by the client, including severe headache and blurred vision, are consistent with neurological manifestations associated with severe pre-eclampsia.
Hyperreflexia refers to an exaggerated reflex response, and clonus refers to rhythmic contractions of a muscle when it is passively stretched. Both hyperreflexia and clonus are indicative of central nervous system (CNS) hyperexcitability. Cerebral edema, which is the swelling of the brain due to fluid accumulation, can lead to increased intracranial pressure and neurological symptoms such as headache, vision changes, hyperreflexia, and clonus.
While other complications such as pulmonary edema (B), hemolysis (C), and thrombocytopenia (D) can occur in severe pre-eclampsia, they are not directly associated with the reported symptoms of severe headache, blurred vision, hyperreflexia, and clonus.
Correct Answer is A
Explanation
This indicates a therapeutic level of magnesium sulfate for a client with severe pre-eclampsia who is receiving magnesium sulfate.According to some sources, the effective therapeutic serum magnesium level is 1.8–3.0 mmol/L, which corresponds to 4.2–7 mg/dL or 3.5–7 mEq/L.
Choice B is wrong because serum calcium level of 8.5 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice C is wrong because serum creatinine level of 1.2 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice D is wrong because serum potassium level of 3.5 mEq/L is at the lower end of the normal range and does not indicate the effect of magnesium sulfate.
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