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

Explanation

The correct answer is choice B, D and E. These are signs and symptoms of preeclampsia, a serious complication of gestational hypertension that can affect the mother and the baby.Preeclampsia is marked by high blood pressure and protein in urine or other signs of organ damage.

Choice A is wrong because swelling of the face, hands or feet is a common symptom of pregnancy and does not necessarily indicate preeclampsia.However, sudden or severe swelling can be a warning sign and should be checked by a healthcare provider.

Choice C is wrong because severe headache is a symptom of preeclampsia, not gestational hypertension.Gestational hypertension is high blood pressure that develops after 20 weeks of pregnancy and does not have protein in urine or other signs of organ damage.

Some normal ranges for blood pressure during pregnancy are:

• Systolic (top number): less than 140 mm Hg

• Diastolic (bottom number): less than 90 mm Hg

Some normal ranges for protein in urine during pregnancy are:

• Less than 300 mg per 24 hours

• Less than 0.3 g per liter

A. Hemoglobin 12 g/dL, platelets 150,000/mm3, AST 20 U/L, ALT 18 U/L B. Hemoglobin 10 g/dL, platelets 100,000/mm3, AST 40 U/L, ALT 35 U/L C. Hemoglobin 8 g/dL, platelets 50,000/mm3, AST 80 U/L, ALT 70 U/L D. Hemoglobin 6 g/dL, platelets 25,000/mm3, AST 120 U/L, ALT 100 U/L

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.

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

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Naxlex Comprehensive Predictor Exams

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

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

Explanation

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?

Correct Answer is D

Explanation

(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?

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

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 findings would indicate that a client with preeclampsia is experiencing HELLP syndrome?

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

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 risk factors for gestational hypertension with a group of pregnant clients at a prenatal clinic. Which of the following factors should the nurse include? (Select all that apply.).

A nurse is caring for a client who has severe preeclampsia and is receiving hydralazine IV bolus for blood pressure management. Which of the following adverse effects should the nurse monitor for? (Select all that apply.)