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 C

Explanation

The correct answer is choice C) Elevated serum bilirubin levels.This is because bilirubin is a product of hemolysis (the breakdown of red blood cells), which is one of the components of HELLP syndrome.Elevated serum bilirubin levels indicate that there is excessive hemolysis occurring in the body, which can lead to jaundice and liver damage.

Choice A) Elevated serum creatinine levels is wrong because creatinine is a marker of kidney function, not liver function or hemolysis.While kidney failure can occur as a complication of HELLP syndrome, it is not a diagnostic criterion.

Choice B) Elevated serum uric acid levels is wrong because uric acid is also a marker of kidney function, not liver function or hemolysis.Uric acid levels can be elevated in preeclampsia, but not specifically in HELLP syndrome.

Choice D) Elevated serum glucose levels is wrong because glucose is not related to liver function or hemolysis.Glucose levels can be elevated in gestational diabetes, but not in HELLP syndrome.

Normal ranges for these tests are:

• Serum bilirubin: 0.3 to 1.2 mg/dL

• Serum creatinine: 0.6 to 1.1 mg/dL

• Serum uric acid: 2.4 to 6.0 mg/dL

• Serum glucose: 70 to 100 mg/dL

A. Severe headache B. Chest pain C. Nausea or vomiting D. Swelling of the face, hands or feet

Correct Answer is D

Explanation

The correct answer is choice D) Swelling of the face, hands or feet.This is one of the signs and symptoms of gestational hypertension, which is high blood pressure that begins after 20 weeks of pregnancy and goes away after delivery.Gestational hypertension can lead to complications for both the mother and the baby, such as preeclampsia, which is a severe condition that causes protein in the urine and other problems.

Choice A) Severe headache is wrong because it is not a specific sign of gestational hypertension, but it can be a symptom of preeclampsia, which is a possible complication of gestational hypertension.

Choice B) Chest pain is wrong because it is not a common sign of gestational hypertension, but it can be a sign of a serious heart problem or a pulmonary embolism, which is a blood clot in the lungs.Chest pain during pregnancy should be evaluated by a doctor as soon as possible.

Choice C) Nausea or vomiting is wrong because it is not a typical sign of gestational hypertension, but it can be a symptom of preeclampsia or other conditions such as hyperemesis gravidarum, which is severe nausea and vomiting during pregnancy that can lead to dehydration and weight loss.

Normal blood pressure ranges for pregnant women are below 120/80 mm Hg.Gestational hypertension is diagnosed when the blood pressure is greater than or equal to 140/90 mm Hg after 20 weeks of pregnancy.

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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

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

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

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.)

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 caring for a client with gestational hypertension who is at risk for developing preeclampsia. Which of the following interventions should the nurse implement to prevent this complication? (Select all that apply.).

A nurse is caring for a client with gestational hypertension who has been prescribed methyldopa (Aldomet) to control blood pressure during pregnancy. Which of the following side effects should the nurse monitor for?

(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?

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?

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

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?