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.)

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.

The correct answer is choice C. Choice C is wrong because breastfeeding is not contraindicated for women with gestational hypertension.Breastfeeding has many benefits for both the mother and the baby, and it does not affect blood pressure.

Choice A is correct because blood pressure medication should be continued as prescribed until the next check-up.Stopping medication abruptly can cause a rebound increase in blood pressure and increase the risk of complications.

Choice B is correct because headache, blurred vision, or abdominal pain are signs of severe preeclampsia, a serious complication of gestational hypertension that can affect the brain, liver, and kidneys.These symptoms should be reported to the provider immediately.

Choice D is correct because limiting salt intake and drinking plenty of fluids can help lower blood pressure and prevent fluid retention.

Salt can cause the body to hold on to excess water, which increases blood volume and blood pressure.Fluids can help flush out excess salt and keep the body hydrated.

Choice E is correct because weighing oneself daily and reporting any sudden weight gain to the provider can help monitor fluid balance and detect signs of preeclampsia.A weight gain of more than 2 pounds in a week or 5 pounds in a month may indicate fluid accumulation and increased blood pressure.