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 ["A","B","C","D"]
Explanation
The correct answer is choice A, B, C and D.These choices reflect the laboratory findings that are expected in a client who has HELLP syndrome.HELLP syndrome is a rare pregnancy complication that is a type of preeclampsia and has similar symptoms.It can cause serious blood and liver problems.
Choice A is correct because hemoglobin of 9 g/dL indicates hemolysis, which is the breaking down of red blood cells.The normal range of hemoglobin for pregnant women is 11 to 16 g/dL.
Choice B is correct because platelets of 90,000/mm3 indicate thrombocytopenia, which is a low platelet count.The normal range of platelets for pregnant women is 150,000 to 400,000/mm3.
Choice C is correct because AST of 120 U/L indicates elevated liver enzymes, which reflect liver injury.The normal range of AST for pregnant women is 10 to 40 U/L.
Choice D is correct because LDH of 600 U/L indicates elevated lactate dehydrogenase, which is a marker of hemolysis.The normal range of LDH for pregnant women is 140 to 280 U/L.
Choice E is wrong because WBC of 15,000/mm3 indicates leukocytosis, which is not a feature of HELLP syndrome.The normal range of WBC for pregnant women is 5,000 to 15,000/mm3.
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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