A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago.

Which of the following instructions should the nurse include?

“You can stop taking your blood pressure medication now that you have delivered your baby.”

“You should avoid breastfeeding your baby until your blood pressure is normal.”

“You should report any headache or visual changes to your doctor immediately.”

“You should limit your fluid intake to prevent fluid overload.”

Answer and Explanation

The Correct Answer is C

The nurse should instruct the client to report any headache or visual changes to the doctor immediately, as these are signs of worsening preeclampsia that can lead to serious complications such as stroke, eclampsia, or HELLP syndrome. Preeclampsia can persist or even begin after delivery, most often within 48 hours, so the client should monitor her blood pressure and symptoms until they resolve.

Choice A is wrong because the client should not stop taking her blood pressure medication without consulting her doctor. Blood pressure medication helps lower the blood pressure and protects the organs from damage. The blood pressure usually returns to normal within several days to weeks after delivery, but some clients may need medication for longer.

Choice B is wrong because the client should not avoid breastfeeding her baby unless there is a medical reason to do so. Breastfeeding has many benefits for both the mother and the baby, and does not affect the blood pressure or the preeclampsia.

Choice D is wrong because the client should not limit her fluid intake to prevent fluid overload. Fluid overload is not a common complication of preeclampsia, and limiting fluids can cause dehydration and affect the milk supply for breastfeeding.

The client should drink enough fluids to stay hydrated and follow a balanced diet.

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

Explanation

The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.

Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.

Normal ranges for the assessments are:

• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)

• Respiratory rate: 12 to 20 breaths per minute

• Urine output: at least 30 mL per hour

• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)

A. Age over 35 years B. First pregnancy C. Obesity D. Diabetes mellitus E. Multiple gestation

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

Explanation

The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.

Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.

Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.

Normal ranges for blood pressure and proteinuria in pregnancy are:

• Blood pressure: less than 140/90 mmHg

• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample

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A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

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

Explanation

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

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

Explanation

A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

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A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago. Which of the following instructions should the nurse include?

A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should alert the nurse to suspect magnesium toxicity?

A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following actions should the nurse take before giving the medication? (Select all that apply.)

A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago.

Which of the following instructions should the nurse include?