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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
The correct answer is choice A, C, D and E. Here is why:
• Choice A is correct becausedisseminated intravascular coagulation (DIC)is a blood clotting disorder that can develop as a complication of HELLP syndrome.DIC can result in excessive bleeding or blood clots in various organs.
• Choice B is wrong becauseacute kidney injuryis not a common complication of HELLP syndrome.However, preeclampsia can cause kidney damage and proteinuria (high levels of protein in the urine).
• Choice C is correct becausepulmonary edemais a condition where fluid accumulates in and around the lungs, impairing oxygen absorption.It can occur as a complication of HELLP syndrome due to high blood pressure and fluid overload.
• Choice D is correct becauseplacental abruptionis a condition where the placenta separates from the uterus before delivery.
It can cause severe bleeding and fetal distress.It can occur as a complication of HELLP syndrome due to high blood pressure and abnormal blood clotting.
• Choice E is correct becausefetal growth restrictionis a condition where the fetus does not grow as expected.It can occur as a complication of HELLP syndrome due to reduced blood flow and oxygen delivery to the placenta.
Normal ranges for liver enzymes are:
• Alanine aminotransferase (ALT): 7 to 55 units per liter (U/L)
• Aspartate aminotransferase (AST): 8 to 48 U/L
• Alkaline phosphatase (ALP): 45 to 115 U/L
Normal range for platelet count is:
• 150,000 to 450,000 platelets per microlitre.
Correct Answer is ["C","E"]
Explanation
The correct answer is choice C and E.A platelet count of 100,000/mm3 is low and indicates a risk of bleeding due to preeclampsia.A urine output of 20 mL/hour is also low and suggests kidney impairment due to magnesium sulfate therapy.
Both of these results should be reported to the provider as they may require intervention.
Choice A is wrong because a serum creatinine of 1.2 mg/dL is within the normal range of 0.6 to 1.3 mg/dL for womenand does not indicate kidney dysfunction.
Choice B is wrong because liver enzymes of 40 U/L are within the normal range of 7 to 55 U/L for women and do not indicate liver damage.
Choice D is wrong because a coagulation profile of 12 seconds is within the normal range of 11 to 13.5 seconds for women and does not indicate a clotting disorder.
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