A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands.

Which intervention is the priority for this client?

Administer magnesium sulfate as prescribed

Monitor the fetal heart rate and movement

Encourage bed rest in a left lateral position

Educate the client about the signs of eclampsia

Answer and Explanation

The Correct Answer is C

Encourage bed rest in a left lateral position.

This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus. The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.

Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.

Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.

Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia. Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.

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Correct Answer is ["A","B","D","E"]

Explanation

The correct answer is choice A, B, D and E. These are all signs of severe preeclampsia that indicate organ damage and require immediate medical attention.According to Mayo Clinic, preeclampsia is a complication of pregnancy that causes high blood pressure, protein in the urine, or other signs of organ damage after 20 weeks of gestation.

Choice A is correct because epigastric pain can indicate liver damage or bleeding in the abdomen due to preeclampsia.

Choice B is correct because blurred vision or light sensitivity can indicate brain damage or increased pressure in the skull due to preeclampsia.

Choice C is wrong because facial edema is a common symptom of normal pregnancy and does not necessarily indicate preeclampsia.

Choice D is correct because hyperreflexia can indicate nervous system damage or increased pressure in the skull due to preeclampsia.

Choice E is correct because oliguria can indicate kidney damage or decreased blood flow to the kidneys due to preeclampsia.

Complications In Pregnancy Part II: Hypertensive Disorders Of Pregnancy And Vaginal Bleeding

A. Urinary output of 25 mL/hour B. Respiratory rate of 14 breaths/minute C. Deep tendon reflexes 1+ D. Serum magnesium level of 6 mg/dL

Correct Answer is A

Explanation

A. Urinary output of 25 mL/hour.This indicates magnesium toxicity and requires immediate intervention because it means the kidneys are not functioning properly and magnesium is not being excreted.Magnesium toxicity can cause life-threatening complications such as respiratory depression, cardiac arrest, and coma.

B. Respiratory rate of 14 breaths/minute is normal and does not indicate magnesium toxicity.A respiratory rate of less than 12 breaths/minute or more than 20 breaths/minute would be abnormal and require further assessment.

C. Deep tendon reflexes 1+ are normal and do not indicate magnesium toxicity.A loss of deep tendon reflexes or clonus would indicate magnesium toxicity and require immediate intervention.

D. Serum magnesium level of 6 mg/dL is within the therapeutic range for preeclampsia and does not indicate magnesium toxicity.

The therapeutic range for preeclampsia is 4 to 7 mg/dL.A serum magnesium level of more than 8 mg/dL would indicate magnesium toxicity and require immediate intervention.

Magnesium Sulfate Toxicity

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A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands. Which intervention is the priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

(Select all that apply) A nurse is assessing a client who is 32 weeks pregnant and has a diagnosis of severe preeclampsia. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which of the following findings would indicate magnesium toxicity and require immediate intervention?

Correct Answer is A

Explanation

A nurse is providing discharge instructions to a client who had pre-eclampsia and delivered a healthy baby. Which statement by the client indicates a need for further teaching?

A nurse is assessing a client with severe pre-eclampsia who reports a severe headache and blurred vision. The nurse notes that the client has hyperreflexia with clonus. What is the most likely explanation for these findings?

A nurse is providing discharge teaching to a client who had preeclampsia and delivered a healthy baby at 38 weeks of gestation. Which of the following instructions should the nurse include in the teaching?

A client who is 36 weeks pregnant is admitted to the hospital with a diagnosis of eclampsia. She has a history of chronic hypertension and gestational diabetes. The nurse anticipates that the client will receive which of the following medications to prevent seizures?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate infusion. Which of the following assessments is most important for the nurse to monitor?

A nurse is reviewing the laboratory results of a client who has mild preeclampsia. Which of the following findings would indicate a need for further evaluation?

A nurse is preparing to administer hydralazine to a client with severe pre-eclampsia who has a blood pressure of 170/110 mmHg. What is the expected outcome of this medication?

A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands. Which intervention is the priority for this client?

A nurse is caring for a client with mild pre-eclampsia who has a blood pressure of 150/95 mmHg, proteinuria of 400 mg/24 hours, and edema of the face and hands.

Which intervention is the priority for this client?