What is a priority nursing intervention for a woman with severe preeclampsia who is receiving hydralazine IV.
Assess for orthostatic hypotension
Monitor fetal heart rate continuously
Encourage oral fluid intake
Administer oxygen via nasal cannula
The Correct Answer is B
The correct answer is choice B. Monitor fetal heart rate continuously. This is because hydralazine is a vasodilator that lowers blood pressure and may cause tachycardia. Tachycardia can affect the fetal heart rate and oxygenation, so continuous monitoring is essential to detect any signs of fetal distress.
Choice A is wrong because hydralazine does not cause orthostatic hypotension, but rather a reflex increase in heart rate and cardiac output.
Orthostatic hypotension is more likely to occur with other antihypertensive drugs such as alpha-blockers or diuretics.
Choice C is wrong because encouraging oral fluid intake may worsen the fluid retention and edema that are common in preeclampsia. Fluid intake should be restricted to avoid pulmonary edema and cerebral edema.
Choice D is wrong because administering oxygen via nasal cannula is not a priority intervention for a woman with severe preeclampsia who is receiving hydralazine IV. Oxygen therapy may be indicated if the woman develops signs of hypoxia, such as dyspnea, cyanosis, or low oxygen saturation. However, oxygen therapy should be used with caution as it may increase oxidative stress and placental vasoconstriction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is choice A, C and D.These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
Choice B is wrong because corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
Choice E is wrong because a diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia.A balanced diet with adequate calcium, magnesium and antioxidants is advised.
Correct Answer is C
Explanation
The correct answer is choice C) Elevated serum bilirubin levels.This is because bilirubin is a product of hemolysis (the breakdown of red blood cells), which is one of the components of HELLP syndrome.Elevated serum bilirubin levels indicate that there is excessive hemolysis occurring in the body, which can lead to jaundice and liver damage.
Choice A) Elevated serum creatinine levels is wrong because creatinine is a marker of kidney function, not liver function or hemolysis.While kidney failure can occur as a complication of HELLP syndrome, it is not a diagnostic criterion.
Choice B) Elevated serum uric acid levels is wrong because uric acid is also a marker of kidney function, not liver function or hemolysis.Uric acid levels can be elevated in preeclampsia, but not specifically in HELLP syndrome.
Choice D) Elevated serum glucose levels is wrong because glucose is not related to liver function or hemolysis.Glucose levels can be elevated in gestational diabetes, but not in HELLP syndrome.
Normal ranges for these tests are:
• Serum bilirubin: 0.3 to 1.2 mg/dL
• Serum creatinine: 0.6 to 1.1 mg/dL
• Serum uric acid: 2.4 to 6.0 mg/dL
• Serum glucose: 70 to 100 mg/dL
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