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 ["A","B","D","E"]

Explanation

The correct answer is choice C. Choice C is wrong because breastfeeding is not contraindicated for women with gestational hypertension.Breastfeeding has many benefits for both the mother and the baby, and it does not affect blood pressure.

Choice A is correct because blood pressure medication should be continued as prescribed until the next check-up.Stopping medication abruptly can cause a rebound increase in blood pressure and increase the risk of complications.

Choice B is correct because headache, blurred vision, or abdominal pain are signs of severe preeclampsia, a serious complication of gestational hypertension that can affect the brain, liver, and kidneys.These symptoms should be reported to the provider immediately.

Choice D is correct because limiting salt intake and drinking plenty of fluids can help lower blood pressure and prevent fluid retention.

Salt can cause the body to hold on to excess water, which increases blood volume and blood pressure.Fluids can help flush out excess salt and keep the body hydrated.

Choice E is correct because weighing oneself daily and reporting any sudden weight gain to the provider can help monitor fluid balance and detect signs of preeclampsia.A weight gain of more than 2 pounds in a week or 5 pounds in a month may indicate fluid accumulation and increased blood pressure.

A. Respiratory rate and depth B. Urine output and color C. Blood pressure and heart rate D. Level of consciousness and reflexes

Correct Answer is D

Explanation

The correct answer is choice D) Level of consciousness and reflexes.This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes.These are signs that the dose of magnesium sulfate should be reduced or stopped.

The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.

Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.

Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures.However, urine output should be monitored to ensure adequate hydration and renal function.

Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy.Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.

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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

(Select all that apply). A nurse is providing discharge teaching to a client with gestational hypertension who delivered a healthy baby two days ago. Which of the following statements by the client would indicate a need for further teaching?

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

Explanation

A nurse is caring for a client with gestational hypertension who has been prescribed magnesium sulfate to prevent seizures related to preeclampsia. Which of the following assessments should the nurse prioritize?

Correct Answer is D

Explanation

A nurse is administering nifedipine to a client with gestational hypertension as prescribed by the provider. Which of the following actions would the nurse take to ensure safe administration of this medication?

Which of the following interventions should be included in the plan of care for a client with severe preeclampsia? (Select all that apply.)

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

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

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 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?

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?

Which of the following factors increases a woman’s risk for developing gestational hypertension.