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

Administer antihypertensive medications as prescribed

Monitor urine output hourly

Encourage bed rest in a quiet environment

Administer magnesium sulfate as prescribed

Monitor fetal heart rate continuously

Answer and Explanation

Correct Answer : A,B,C,D

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.

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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

A. Administer the medication over 30 min using an infusion pump B. Place the client in a supine position with a wedge under the right hip C. Monitor the client’s blood pressure every 15 min during the infusion D. Have calcium gluconate available at the bedside as an antidote.

Correct Answer is D

Explanation

The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote.Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.

Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.

A shorter infusion time may increase the risk of adverse effects.

Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.

Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.

Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.

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

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Naxlex Comprehensive Predictor Exams

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

A nurse is preparing to administer an IV loading dose of magnesium sulfate to a client who has preeclampsia with severe features. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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

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 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?

(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?

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?

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?

A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia. Which of the following assessments should the nurse prioritize?

A nurse is caring for a client who has severe preeclampsia and is receiving hydralazine IV bolus for blood pressure management. Which of the following adverse effects should the nurse monitor for? (Select all that apply.)