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

Administer antihypertensive medications as prescribed

Monitor urine output hourly

Encourage bed rest in a quiet environment

Administer magnesium sulfate as prescribed

Monitor fetal heart rate continuously

Answer and Explanation

Correct Answer : A,B,C,D

The correct answer is choices A, B, C and D. These are all interventions that can help lower blood pressure, prevent seizures, and monitor the health of the mother and the baby in severe preeclampsia.

Choice E is wrong because continuous fetal heart rate monitoring is not necessary for severe preeclampsia unless there are signs of fetal distress or labor. Intermittent auscultation or nonstress test can be used instead to assess fetal well-being.

Normal ranges for blood pressure are below 140/90 mmHg, for urine output are 30 mL/hour or more, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT. Magnesium sulfate levels should be maintained between 4 to 7 mg/dL to prevent toxicity. Fetal heart rate should be between 110 to 160 beats per minute.

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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. Serum magnesium level B. Serum potassium level C. Serum sodium level D. Serum calcium level

Correct Answer is A

Explanation

The correct answer is choice A) Serum magnesium level.Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia.It is often given intravenously and can also be used to prolong pregnancy for up to two days.However, magnesium sulfate can also cause side effects and toxicity, such as respiratory depression, muscle weakness, and cardiac arrest.Therefore, the nurse should monitor the serum magnesium level to ensure that it is within the therapeutic range of 4 to 7 mg/dL.

Choice B) Serum potassium level is wrong because magnesium sulfate does not affect the potassium level significantly.

Potassium is an electrolyte that regulates the nerve and muscle function, especially the heart.

The normal range of potassium level is 3.5 to 5.0 mEq/L.

Choice C) Serum sodium level is wrong because magnesium sulfate does not affect the sodium level significantly.

Sodium is another electrolyte that helps maintain fluid balance and blood pressure.

The normal range of sodium level is 135 to 145 mEq/L.

Choice D) Serum calcium level is wrong because magnesium sulfate does not affect the calcium level significantly.

Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction.

The normal range of calcium level is 8.5 to 10.2 mg/dL.

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

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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

A client is diagnosed with preeclampsia and is receiving magnesium sulfate IV for seizure prophylaxis. The nurse should monitor which of the following laboratory values?

Correct Answer is A

Explanation

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

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

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 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?

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

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?

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.)

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