A nurse is teaching a pregnant client about the risk factors for pre-eclampsia.

Which of the following should the nurse include? (Select all that apply).

Age over 35 years

First pregnancy

Obesity

Diabetes mellitus

Multiple gestation

Answer and Explanation

Correct Answer : B,C,D,E

The correct answer is choices B, C, D, and E. These are all risk factors for pre-eclampsia according to various sources.

Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.

Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage. It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth. It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens. Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.

Normal ranges for blood pressure and proteinuria in pregnancy are:

• Blood pressure: less than 140/90 mmHg

• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample

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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)

A. Respiratory rate of 10 breaths/minute B. Deep tendon reflexes of 2+ C. Urinary output of 40 mL/hour D. Serum magnesium level of 6 mEq/L

Correct Answer is A

Explanation

Respiratory rate of 10 breaths/minute.This indicates that the client is experiencingmagnesium toxicity, which can causemuscle weakness,difficulty breathing, andcardiac arrest.The normal respiratory rate for adults is 12 to 20 breaths/minute.

Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.

Choice C is wrong because urinary output of 40 mL/hour is within the normal range of 30 to 50 mL/hour.Magnesium toxicity can cause urine retention, not increased output.

Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L.Magnesium toxicity occurs when the level is above 2.6 mEq/L.

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A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

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?

Correct Answer is A

Explanation

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia. Which outcome would indicate that the therapy is successful?

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse identify as an indication of magnesium sulfate toxicity?

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

A nurse is providing discharge teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?

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?

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (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 teaching a pregnant client about the risk factors for pre-eclampsia.

Which of the following should the nurse include? (Select all that apply).