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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.These are all risk factors for gestational hypertension according to various sources.
Some possible explanations for each choice are:
• Choice A: Maternal age over 35 years.Older women are more likely to have chronic hypertension, diabetes, or other conditions that increase the risk of gestational hypertension.
• Choice B: First pregnancy.Women who are pregnant for the first time are more likely to develop gestational hypertension than women who have had previous pregnancies.
• Choice C: Multiple gestation.Women who are carrying twins, triplets, or more are more likely to have gestational hypertension because of the increased placental mass and blood volume.
• Choice D: History of diabetes mellitus.This is not a risk factor for gestational hypertension, but it is a risk factor for preeclampsia, which is a more severe form of hypertension that involves proteinuria and organ damage.
Preeclampsia can develop from gestational hypertension or occur independently.
• Choice E: African American race.African American women are more likely to have gestational hypertension than women of other races or ethnicities.
This may be due to genetic, environmental, or social factors that affect blood pressure regulation.
Normal ranges for blood pressure during pregnancy are less than 140/90 mmHg.Gestational hypertension is diagnosed when blood pressure is greater than or equal to 140/90 mmHg after 20 weeks of pregnancy and there is no proteinuria or other signs of preeclampsia.Gestational hypertension usually goes away after delivery, but it can increase the risk of complications for both the mother and the baby.
Correct Answer is D
Explanation
The correct answer is choice D. Have calcium gluconate available at the bedside as an antidote.Magnesium sulfate is used to prevent and treat seizures in women with severe preeclampsia or eclampsia.However, it can also cause toxicity and respiratory depression if the serum level is too high.Calcium gluconate is the antidote for magnesium sulfate toxicity and should be readily available at the bedside.
Choice A is wrong because the medication should be administered over 20-30 minutes using an infusion pump.
A shorter infusion time may increase the risk of adverse effects.
Choice B is wrong because the client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
Choice C is wrong because the client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
Blood pressure is an indicator of the severity of preeclampsia and the effectiveness of magnesium sulfate therapy.
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