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 B
Explanation
Methyldopa is a drug that lowers blood pressure by reducing the activity of the sympathetic nervous system.
One of the possible side effects of methyldopa is hypotension, which means abnormally low blood pressure.Hypotension can cause dizziness, fainting, and shock.
Choice A) Bradycardia is wrong because methyldopa does not affect the heart rate directly.Bradycardia means a slow heart rate, which can be caused by other drugs or conditions.
Choice C) Hyperkalemia is wrong because methyldopa does not affect the potassium levels in the blood.Hyperkalemia means high potassium levels, which can be caused by kidney problems or other drugs.
Choice D) Hyperglycemia is wrong because methyldopa does not affect the glucose levels in the blood.Hyperglycemia means high glucose levels, which can be caused by diabetes or other conditions.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for heart rate are 60 to 100 beats per minute, for potassium are 3.5 to 5.0 mmol/L, and for glucose are 70 to 100 mg/dL.
Correct Answer is A
Explanation
The correct answer is choice A. Cerebral hemorrhage.Eclampsia is a severe complication of preeclampsia that causes seizures and can lead to stroke or death.Cerebral hemorrhage is bleeding in the brain that can result from high blood pressure and swelling in the brain caused by eclampsia.It is one of the most common causes of death in women with eclampsia.
Choice B. Pulmonary edema is wrong because it is not the most common cause of death in women with eclampsia.
Pulmonary edema is fluid accumulation in the lungs that can impair breathing and oxygen exchange.It can occur as a complication of eclampsia, but it is less frequent than cerebral hemorrhage.
Choice C. Liver rupture is wrong because it is not the most common cause of death in women with eclampsia.
Liver rupture is a rare but serious complication of eclampsia that involves bleeding from the liver due to increased pressure and damage to the liver tissue.It can cause severe abdominal pain, shock and death.
Choice D. Disseminated intravascular coagulation (DIC) is wrong because it is not the most common cause of death in women with eclampsia.
DIC is a condition where the blood clotting system becomes overactive and forms clots throughout the body, leading to bleeding and organ failure.It can occur as a complication of eclampsia, but it is less common than cerebral hemorrhage.
Normal ranges for blood pressure are below 140/90 mmHg and for proteinuria are below 300 mg/24 hours or below 30 mg/dL in a urine sample.
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