A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 34 weeks of gestation.
Which of the following statements by the client indicates a need for further teaching?
“I will need to monitor my blood pressure at home for a few weeks.”
“I will call my doctor if I have any headaches or vision changes.”
“I will avoid taking any over-the-counter pain medications.”
“I will resume my normal activities as soon as possible.”
The Correct Answer is D
“I will resume my normal activities as soon as possible.” This statement indicates a need for further teaching because a woman who had severe pre-eclampsia should rest more often and avoid strenuous activities until her blood pressure is normal and stable. She should also follow up with her doctor regularly and monitor her blood pressure at home.
Choice A is wrong because it is important to monitor blood pressure at home for a few weeks after having pre-eclampsia.
This can help detect any signs of worsening hypertension or organ damage.
Choice B is wrong because it is advisable to call the doctor if there are any headaches or vision changes, as these could be signs of brain injury or eclampsia.
Eclampsia is a serious complication of pre-eclampsia that causes seizures.
Choice C is wrong because some over-the-counter pain medications, such as ibuprofen, can increase blood pressure and should be avoided by women with pre-eclampsia. However, acetaminophen (Tylenol) is usually safe to take for mild pain relief.
Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg. Normal ranges for protein in urine during pregnancy are less than 300 mg in 24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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)
Correct Answer is D
Explanation
The client should have a follow-up visit with the provider in a week.This is because preeclampsia can persist or develop after delivery and requires close monitoring of blood pressure and signs of organ injury.
Choice A is wrong because vaginal bleeding is normal after delivery and does not indicate a complication of preeclampsia.
Choice B is wrong because the client should not stop taking blood pressure medication without consulting the provider.Preeclampsia can cause hypertension that may need treatment even after delivery.
Choice C is wrong because breastfeeding is not contraindicated for women with preeclampsia.Breastfeeding may even lower blood pressure and help the uterus contract.
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