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.”

Answer and Explanation

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.

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Correct Answer is A

Explanation

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

A. Blood pressure of 150/90 mm Hg B. Urine protein of 2+ C. Epigastric pain D. Facial edema

Correct Answer is C

Explanation

This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.

The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.

Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.

Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.

Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.

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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?

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Correct Answer is A

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?

Correct Answer is C

Explanation

A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion. Which finding 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 caring for a client with severe pre-eclampsia who is being induced with oxytocin. The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds. The fetal heart rate is 160 beats/minute with late decelerations. What is the priority nursing action?

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion. What nursing interventions are appropriate for this client? Select all that apply.

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

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?