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?
“I should avoid foods that are high in sodium.”
“I should lie on my left side for at least 2 hours a day.”
“I should check my blood pressure at home every day.”
“I should take a baby aspirin every day as prescribed.”
The Correct Answer is D
“I should take a baby aspirin every day as prescribed.” Taking a baby aspirin daily has been shown to reduce the risk of developing preeclampsia by about 15%. If you have risk factors for preeclampsia, your healthcare provider may recommend starting aspirin in early pregnancy (by 12 weeks gestation).
Choice A is wrong because avoiding foods that are high in sodium does not prevent preeclampsia. Sodium intake does not affect blood pressure in pregnancy.
Choice B is wrong because lying on your left side for at least 2 hours a day does not prevent preeclampsia. However, lying on your left side may help improve blood flow to your placenta and your baby.
Choice C is wrong because checking your blood pressure at home every day does not prevent preeclampsia. However, monitoring your blood pressure at home may help detect signs of preeclampsia early and alert you to seek medical attention if needed.
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Correct Answer is D
Explanation
“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.
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.
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