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","B"]
Explanation
The correct answer is choice A and B. Hydralazine is a drug that lowers blood pressure by relaxing the blood vessels.It can cause some side effects such astachycardia(fast heart rate) andheadache.
These are common and may go away during treatment.
However, if they are severe or persistent, the nurse should monitor the client and report to the doctor.
Choice C is wrong because nausea is not a common side effect of hydralazine.
It may be caused by other factors such as pregnancy or infection.
Choice D is wrong because hyperkalemia (high potassium level in the blood) is not a side effect of hydralazine.
It may be caused by other drugs such as angiotensin-converting enzyme inhibitors or potassium-sparing diuretics.
Choice E is wrong because oliguria (low urine output) is not a side effect of hydralazine.
It may be a sign of kidney damage or dehydration.
The nurse should monitor the client’s fluid intake and output and report any changes to the doctor.
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.
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