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.).
Encourage bed rest in a dark and quiet environment
Administer corticosteroids as prescribed
Monitor fetal heart rate and movement
Assess for headache, visual changes and epigastric pain
Provide a diet high in protein and low in carbohydrates
Correct Answer : A,C,D
The correct answer is choice A, C and D. These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
Choice B is wrong because corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
Choice E is wrong because a diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia. A balanced diet with adequate calcium, magnesium and antioxidants is advised.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
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.
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.
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