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?

Respiratory rate and depth

Urine output and color

Blood pressure and heart rate

Level of consciousness and reflexes

Answer and Explanation

The Correct Answer is D

The correct answer is choice D) Level of consciousness and reflexes. This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes. These are signs that the dose of magnesium sulfate should be reduced or stopped.

The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.

Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.

Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures. However, urine output should be monitored to ensure adequate hydration and renal function.

Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy. Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.

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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. Check blood pressure before and after giving the medication B. Give the medication with grapefruit juice to enhance absorption C. Hold the medication if pulse rate is below 60 beats per minute D. Monitor blood glucose levels for signs of hypoglycemia

Correct Answer is A

Explanation

The correct answer is choice A. Check blood pressure before and after giving the medication.Nifedipine is an antihypertensive medication that is used to treat gestational hypertension.It lowers blood pressure by relaxing the blood vessels and reducing the workload of the heart.Checking blood pressure before and after giving the medication helps to monitor the effectiveness and safety of the treatment.

Choice B is wrong because grapefruit juice can interact with nifedipine and increase its blood levels, which can cause excessive lowering of blood pressure or other side effects.Grapefruit juice should be avoided when taking nifedipine.

Choice C is wrong because nifedipine does not affect the pulse rate significantly.Holding the medication if pulse rate is below 60 beats per minute is more appropriate for beta-blockers, such as labetalol, which are another class of antihypertensive medications that can slow down the heart rate.

Choice D is wrong because nifedipine does not cause hypoglycemia.Monitoring blood glucose levels for signs of hypoglycemia is more relevant for medications that lower blood sugar, such as insulin or oral antidiabetic agents.

Normal ranges for blood pressure and pulse rate during pregnancy are 110-140/60-90 mmHg and 60-100 beats per minute, respectively.Normal range for blood glucose level during pregnancy is 70-110 mg/dL.

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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?

Nursing Test Bank

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

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?

Correct Answer is A

Explanation

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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?