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.”
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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Related Questions
Correct Answer is B
Explanation
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery.The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia.Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia.The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
Correct Answer is A
Explanation
Administer calcium gluconate as an antidote if toxicity occurs.Magnesium sulfate is a mineral that reduces seizure risks in women with severe preeclampsia.However, it can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Calcium gluconate is an antidote that can reverse the effects of magnesium sulfate and restore normal neuromuscular function.
Choice B is wrong because magnesium sulfate does not affect blood glucose levels.
There is no need to monitor the client’s blood glucose level every 4 hours.
Choice C is wrong because the infusion should be discontinued if the client’s respiratory rate is below 12/min, not 16/min.
A low respiratory rate indicates respiratory depression, which is a sign of magnesium toxicity.
Choice D is wrong because the infusion rate should not be increased if the client’s urine output is above 30 mL/hr.Urine output should be at least 30 mL/hr while administering magnesium sulfate to prevent accumulation of the drug in the body.
Increasing the infusion rate can increase the risk of toxicity.
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