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 D
Explanation
The correct answer is choice D. Hemoglobin 6 g/dL, platelets 25,000/mm3, AST 120 U/L, ALT 100 U/L.
This is because HELLP syndrome is a pregnancy complication that causes hemolysis (breaking down of red blood cells), elevated liver enzymes (indicating liver injury), and low platelet count (impairing blood clotting).
Choice A is wrong because hemoglobin 12 g/dL, platelets 150,000/mm3, AST 20 U/L, ALT 18 U/L are all within normal ranges and do not indicate HELLP syndrome.
Choice B is wrong because hemoglobin 10 g/dL, platelets 100,000/mm3, AST 40 U/L, ALT 35 U/L are mildly abnormal and may suggest mild preeclampsia but not HELLP syndrome.
Choice C is wrong because hemoglobin 8 g/dL, platelets 50,000/mm3, AST 80 U/L, ALT 70 U/L are moderately abnormal and may suggest moderate preeclampsia or incomplete HELLP syndrome but not full HELLP syndrome.
Normal ranges for these laboratory tests are:
• Hemoglobin: 11.5 to 16.5 g/dL for women.
• Platelets: 150,000 to 450,000/mm3 for adults.
• AST: 10 to 40 U/L for adults.
• ALT: 7 to 56 U/L for adults.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.