A nurse is caring for a client with gestational hypertension who is at risk for developing preeclampsia.

Which of the following interventions should the nurse implement to prevent this complication? (Select all that apply.).

The correct answer is choice B. The client’s urine output is at least 30 mL/hr.This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.

A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.

Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.

Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.

Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.

A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.

Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.

A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.

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.