(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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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 C
Explanation
Deep tendon reflexes.
The nurse should monitor the client’s deep tendon reflexes to assess for signs of magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.Magnesium sulfate is given to prevent seizures in clients with severe preeclampsia, but it can also have adverse effects on the neuromuscular system.
Choice A is wrong because blood pressure is not the most important assessment for a client receiving magnesium sulfate.
Blood pressure is a manifestation of preeclampsia, but it does not indicate magnesium toxicity.
Choice B is wrong because urine output is not the most important assessment for a client receiving magnesium sulfate.
Urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium, but it does not reflect the level of magnesium in the blood.
Choice D is wrong because fetal heart rate is not the most important assessment for a client receiving magnesium sulfate.
Fetal heart rate is important to monitor for signs of fetal distress, but it does not indicate maternal magnesium toxicity.
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