A nurse is providing discharge teaching to a client who had preeclampsia and delivered a healthy baby at 38 weeks of gestation.
Which of the following instructions should the nurse include in the teaching?
Report any headache that is not relieved by acetaminophen
Expect some vaginal bleeding for up to 6 weeks postpartum
Resume sexual activity as soon as you feel comfortable
Drink at least 3 liters of fluid per day to prevent dehydration
The Correct Answer is A
Report any headache that is not relieved by acetaminophen. This is because a headache that persists despite taking pain medication can be a sign of increased blood pressure or brain swelling, which are serious complications of preeclampsia.
Choice B is wrong because some vaginal bleeding for up to 6 weeks postpartum is normal and expected for any woman who has given birth, regardless of whether she had preeclampsia or not.
Choice C is wrong because resuming sexual activity as soon as you feel comfortable is also a normal recommendation for any woman who has given birth, unless there are other medical reasons to avoid it.
Choice D is wrong because drinking at least 3 liters of fluid per day to prevent dehydration is not necessary for a woman who had preeclampsia. In fact, drinking too much fluid can worsen the swelling and fluid retention that are common in preeclampsia.
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Related Questions
Correct Answer is C
Explanation
Encourage bed rest in a left lateral position.
This is because bed rest can lower blood pressure and improve blood flow to the placenta and the fetus.The left lateral position reduces pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Choice A is wrong because magnesium sulfate is used to prevent seizures in severe preeclampsia or eclampsia, not mild preeclampsia.
Choice B is wrong because monitoring the fetal heart rate and movement is important, but not the priority for this client.
Choice D is wrong because educating the client about the signs of eclampsia is not urgent and may not prevent the progression of preeclampsia.Some signs of eclampsia are severe headaches, blurred vision, nausea, vomiting, abdominal pain and seizures.
Correct Answer is A
Explanation
A. Urinary output of 25 mL/hour.This indicates magnesium toxicity and requires immediate intervention because it means the kidneys are not functioning properly and magnesium is not being excreted.Magnesium toxicity can cause life-threatening complications such as respiratory depression, cardiac arrest, and coma.
B. Respiratory rate of 14 breaths/minute is normal and does not indicate magnesium toxicity.A respiratory rate of less than 12 breaths/minute or more than 20 breaths/minute would be abnormal and require further assessment.
C. Deep tendon reflexes 1+ are normal and do not indicate magnesium toxicity.A loss of deep tendon reflexes or clonus would indicate magnesium toxicity and require immediate intervention.
D. Serum magnesium level of 6 mg/dL is within the therapeutic range for preeclampsia and does not indicate magnesium toxicity.
The therapeutic range for preeclampsia is 4 to 7 mg/dL.A serum magnesium level of more than 8 mg/dL would indicate magnesium toxicity and require immediate intervention.
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