The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?
Blood pressure reading is at the prenatal baseline.
Dependent edema has resolved.
Urinary output has increased.
The client complains of a headache and blurred vision.
The Correct Answer is D
A. Blood pressure reading is at the prenatal baseline. If blood pressure remains stable, it does not indicate worsening preeclampsia.
B. Dependent edema has resolved. A decrease in edema suggests an improvement, not worsening, of preeclampsia.
C. Urinary output has increased. Decreased urinary output is concerning in preeclampsia, while increased output suggests better kidney function.
D. The client complains of a headache and blurred vision. These are signs of severe preeclampsia, indicating possible cerebral edema or hypertensive crisis, which requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. To determine the exact gestational age of the fetus. Gestational age is estimated via ultrasound and fundal height, not an NST.
B. To measure the amniotic fluid volume. Amniotic fluid volume is assessed with an ultrasound and amniotic fluid index (AFI), not an NST.
C. To confirm the presence of labor contractions. An NST does not confirm labor contractions; it evaluates fetal heart rate in response to fetal movement.
D. To assess fetal well-being in cases of suspected fetal growth restriction. An NST evaluates fetal oxygenation and well-being, making it useful in cases of intrauterine growth restriction (IUGR) or other concerns about fetal health.
Correct Answer is A
Explanation
A. Discontinue the medication infusion. Absent deep-tendon reflexes and respiratory depression (RR <12/min) indicate magnesium toxicity. Magnesium sulfate should be discontinued immediately to prevent further complications, including respiratory and cardiac arrest.
B. Prepare for an emergency cesarean birth. Magnesium toxicity does not necessitate an emergency cesarean birth. The priority is to discontinue magnesium sulfate and administer calcium gluconate as an antidote.
C. Place the client in Trendelenburg position. Trendelenburg position does not address magnesium toxicity and could further compromise respiratory function.
D. Assess maternal blood glucose. Magnesium sulfate does not directly affect blood glucose. Assessing blood glucose is not the priority action in this situation.
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