What is a priority nursing intervention for a woman with severe preeclampsia who is receiving hydralazine IV.

Assess for orthostatic hypotension

Monitor fetal heart rate continuously

Encourage oral fluid intake

Administer oxygen via nasal cannula

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Monitor fetal heart rate continuously. This is because hydralazine is a vasodilator that lowers blood pressure and may cause tachycardia. Tachycardia can affect the fetal heart rate and oxygenation, so continuous monitoring is essential to detect any signs of fetal distress.

Choice A is wrong because hydralazine does not cause orthostatic hypotension, but rather a reflex increase in heart rate and cardiac output.

Orthostatic hypotension is more likely to occur with other antihypertensive drugs such as alpha-blockers or diuretics.

Choice C is wrong because encouraging oral fluid intake may worsen the fluid retention and edema that are common in preeclampsia. Fluid intake should be restricted to avoid pulmonary edema and cerebral edema.

Choice D is wrong because administering oxygen via nasal cannula is not a priority intervention for a woman with severe preeclampsia who is receiving hydralazine IV. Oxygen therapy may be indicated if the woman develops signs of hypoxia, such as dyspnea, cyanosis, or low oxygen saturation. However, oxygen therapy should be used with caution as it may increase oxidative stress and placental vasoconstriction.

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Correct Answer is D

Explanation

The correct answer is choice D. All of the above.All of these factors increase a woman’s risk for developing gestational hypertension.

Choice A is wrong because nulliparity (having no previous pregnancies) is a risk factor for gestational hypertension.Rates in nulliparous women range from 6% to 17% while rates in multiparous women range from 2% to 4%.

Choice B is wrong because age younger than 20 years is a risk factor for gestational hypertension.Pregnant women more than 40 years or less than 18 years are at risk of gestational hypertension.

Choice C is wrong because history of chronic renal disease is a risk factor for gestational hypertension.High blood pressure can also cause problems during and after delivery, such as preeclampsia, eclampsia, stroke, and placental abruption.

Gestational hypertension is blood pressure greater than or equal to 140/90 that begins during the latter half of pregnancy (typically after 20 weeks) and goes away after childbirth.It can put the mother and her baby at risk for problems during the pregnancy, such as preterm delivery and low birth weight.

A. The client’s blood pressure is within normal range B. The client’s urine output is at least 30 mL/hr C. The client’s deep tendon reflexes are 2+ D. The client’s respiratory rate is above 16 breaths/min

Correct Answer is B

Explanation

The correct answer is choice B. The client’s urine output is at least 30 mL/hr.This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.

A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.

Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.

Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.

Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.

A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.

Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.

A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.

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What is a priority nursing intervention for a woman with severe preeclampsia who is receiving hydralazine IV.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following factors increases a woman’s risk for developing gestational hypertension.

Correct Answer is D

Explanation

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with severe preeclampsia who is in labor. Which of the following findings would indicate that the therapy is effective?

Correct Answer is B

Explanation

A nurse is caring for a client with gestational hypertension who has been prescribed labetalol (Normodyne) to control blood pressure during pregnancy. Which of the following statements by the client indicates an understanding of the medication?

Which of the following signs and symptoms may indicate worsening condition or preeclampsia in a client with gestational hypertension?

A nurse is reviewing the laboratory results of a client with gestational hypertension who has been diagnosed with HELLP syndrome. Which of the following findings would the nurse expect to see?

A nurse is reviewing laboratory results for a client who has HELLP syndrome. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is reviewing the risk factors for gestational hypertension with a group of pregnant clients at a prenatal clinic. Which of the following factors should the nurse include? (Select all that apply.).

A client is diagnosed with preeclampsia and is receiving magnesium sulfate IV for seizure prophylaxis. The nurse should monitor which of the following laboratory values?

Which of the following is a sign or symptom of gestational hypertension?

A nurse is administering nifedipine to a client with gestational hypertension as prescribed by the provider. Which of the following actions would the nurse take to ensure safe administration of this medication?