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 ["A","B","C","D"]

Explanation

The correct answer is choices A, B, C and D.These are all interventions that can help lower blood pressure, prevent seizures, and monitor the health of the mother and the baby in severe preeclampsia.

Choice E is wrong because continuous fetal heart rate monitoring is not necessary for severe preeclampsia unless there are signs of fetal distress or labor.Intermittent auscultation or nonstress test can be used instead to assess fetal well-being.

Normal ranges for blood pressure are below 140/90 mmHg, for urine output are 30 mL/hour or more, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.Magnesium sulfate levels should be maintained between 4 to 7 mg/dL to prevent toxicity.Fetal heart rate should be between 110 to 160 beats per minute.

A. Swelling of the face, hands or feet B. Decreased urine output or protein in urine C. Severe headache D. Vision changes such as blurring, flashing lights or spots E. Chest pain or shortness of breath.

Correct Answer is ["B","D","E"]

Explanation

The correct answer is choice B, D and E. These are signs and symptoms of preeclampsia, a serious complication of gestational hypertension that can affect the mother and the baby.Preeclampsia is marked by high blood pressure and protein in urine or other signs of organ damage.

Choice A is wrong because swelling of the face, hands or feet is a common symptom of pregnancy and does not necessarily indicate preeclampsia.However, sudden or severe swelling can be a warning sign and should be checked by a healthcare provider.

Choice C is wrong because severe headache is a symptom of preeclampsia, not gestational hypertension.Gestational hypertension is high blood pressure that develops after 20 weeks of pregnancy and does not have protein in urine or other signs of organ damage.

Some normal ranges for blood pressure during pregnancy are:

• Systolic (top number): less than 140 mm Hg

• Diastolic (bottom number): less than 90 mm Hg

Some normal ranges for protein in urine during pregnancy are:

• Less than 300 mg per 24 hours

• Less than 0.3 g per liter

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

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Naxlex Comprehensive Predictor Exams

Which of the following interventions should be included in the plan of care for a client with severe preeclampsia? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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

Correct Answer is ["B","D","E"]

Explanation

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

Which of the following findings would indicate that a client with preeclampsia is experiencing HELLP syndrome?

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 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?

A nurse is caring for a client with gestational hypertension who has been prescribed methyldopa (Aldomet) to control blood pressure during pregnancy. Which of the following side effects should the nurse monitor for?

(Select all that apply). A nurse is providing discharge teaching to a client with gestational hypertension who delivered a healthy baby two days ago. Which of the following statements by the client would indicate a need for further teaching?

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

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?