A nurse is caring for a client who has eclampsia and is receiving magnesium sulfate and hydralazine.

The client’s blood pressure is 150/90 mmHg, pulse is 88/min, respirations are 18/min, and oxygen saturation is 97%.

The nurse notes that the client’s deep tendon reflexes are absent.

Which of the following actions should the nurse take?

“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%.If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).

Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia.Sodium intake does not affect blood pressure in pregnancy.

Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia.However, lying on your left side may help improve blood flow to your placenta and your baby.

Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia.However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.

The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.

• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels.The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.

• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia.Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.

The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.

• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia.Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.

The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.

• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia.Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.

The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.

• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia.The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.