A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.
Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?
Blood pressure of 150/90 mm Hg
Urine protein of 2+
Epigastric pain
Facial edema
The Correct Answer is C
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia. Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Calcium gluconate is the antidote for magnesium sulfate toxicity because it reverses the effects of magnesium on the neuromuscular and cardiovascular systems.
Magnesium sulfate can cause respiratory depression, hypotension, bradycardia, and cardiac arrest in high doses.
Choice B. Naloxone is wrong because it is the antidote for opioid overdose, not magnesium sulfate toxicity.
Naloxone blocks the opioid receptors and restores breathing and consciousness.
Choice C. Flumazenil is wrong because it is the antidote for benzodiazepine overdose, not magnesium sulfate toxicity.
Flumazenil binds to the benzodiazepine receptors and reverses the sedative and hypnotic effects.
Choice D. Protamine sulfate is wrong because it is the antidote for heparin overdose, not magnesium sulfate toxicity.
Protamine sulfate neutralizes the anticoagulant effect of heparin and prevents bleeding.
Normal ranges for magnesium are 1.5 to 2.5 mEq/L or 0.75 to 1.25 mmol/L.
Correct Answer is A
Explanation
“You may feel warm and flushed while receiving this medication.” This is a common side effect of magnesium sulfate therapy, which is used to prevent seizures in women with severe pre-eclampsia.Magnesium sulfate can also help prolong a pregnancy for up to two days by relaxing the uterus.
Choice B is wrong because magnesium sulfate can cause fluid retention and swelling, not dehydration.Choice C is wrong because magnesium sulfate can cause drowsiness and lethargy, not insomnia and restlessness.Choice D is wrong because magnesium sulfate can cause decreased blood pressure and heart rate, not inflammation and infection at the infusion site.
Normal ranges for blood pressure are below 140/90 mm Hg, for platelet count are 150,000 to 450,000 per microliter of blood, and for protein in urine are less than 300 milligrams per day.
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