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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote.Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.

Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.

A shorter infusion time may increase the risk of adverse effects.

Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.

Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.

Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.

A. Severe headache B. Vision changes such as blurring, flashing lights or spots C. Chest pain or shortness of breath D. Nausea or vomiting E. Abdominal pain or tenderness

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

Explanation

The correct answer ischoice A, B, D and E.These are all signs and symptoms that may indicate worsening condition or preeclampsia in a client with gestational hypertension.Preeclampsia is a complication of pregnancy that is marked by high blood pressure and presence of proteins in urine.

Choice C is wrong because chest pain or shortness of breath are not typical symptoms of preeclampsia, but they may indicate other serious conditions such as heart problems or pulmonary edema.

If a client with gestational hypertension experiences these symptoms, they should seek immediate medical attention.

Normal ranges for blood pressure and proteinuria are:

• Blood pressure: less than 140/90 mm Hg.

• Proteinuria: less than 300 mg in a 24-hour urine collection or less than 30 mg/dL in a random urine sample.

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What is a priority nursing intervention for a woman with severe preeclampsia who is receiving hydralazine IV.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an IV loading dose of magnesium sulfate to a client who has preeclampsia with severe features. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Which of the following signs and symptoms may indicate worsening condition or preeclampsia in a client with gestational hypertension?

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

Explanation

Which of the following findings would indicate that a client with preeclampsia is experiencing HELLP syndrome?

What is the most common cause of death in women with eclampsia.

Which of the following is a sign or symptom of gestational hypertension?

A client is diagnosed with preeclampsia and is receiving magnesium sulfate IV for seizure prophylaxis. The nurse should monitor which of the following laboratory values?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with severe preeclampsia who is in labor. Which of the following findings would indicate that the therapy is effective?

A nurse is reviewing the laboratory results of a client with gestational hypertension who has been diagnosed with HELLP syndrome. Which of the following findings would the nurse expect to see?

A nurse is reviewing laboratory results for a client who has HELLP syndrome. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client with gestational hypertension who has been prescribed labetalol (Normodyne) to control blood pressure during pregnancy. Which of the following statements by the client indicates an understanding of the medication?