A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth.

The nurse should instruct the client to report which of the following findings to the provider?

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.

The correct answer is choice A and E. The nurse should check the client’s blood pressure and magnesium level before giving hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously.

• Choice A is correct because hydralazine is an antihypertensive drug that lowers blood pressure by relaxing blood vessels.The nurse should monitor the client’s blood pressure before and after giving hydralazine to ensure that it is within the target range and to avoid hypotension or rebound hypertension.

• Choice B is wrong because pulse oximetry is not directly related to hydralazine administration or pre-eclampsia.Pulse oximetry measures the oxygen saturation of hemoglobin in the blood and can be affected by factors such as anemia, hypothermia, nail polish, or movement.

The nurse should monitor the client’s pulse oximetry as part of routine care, but it is not a priority before giving hydralazine.

• Choice C is wrong because checking the client’s reflexes is not directly related to hydralazine administration or pre-eclampsia.Reflexes are assessed to monitor for signs of magnesium toxicity, which can cause muscle weakness, respiratory depression, and cardiac arrest.

The nurse should check the client’s reflexes as part of routine care, but it is not a priority before giving hydralazine.

• Choice D is wrong because checking the client’s urine specific gravity is not directly related to hydralazine administration or pre-eclampsia.Urine specific gravity measures the concentration of solutes in the urine and can be affected by factors such as hydration status, renal function, or diuretic use.

The nurse should monitor the client’s urine specific gravity as part of routine care, but it is not a priority before giving hydralazine.

• Choice E is correct because magnesium sulfate is a drug that prevents and treats seizures in women with severe pre-eclampsia or eclampsia.The nurse should monitor the client’s magnesium level before and after giving magnesium sulfate to ensure that it is within the therapeutic range and to avoid magnesium toxicity.