Which of the following signs and symptoms may indicate worsening condition or preeclampsia in a client with gestational hypertension?
Severe headache
Vision changes such as blurring, flashing lights or spots
Chest pain or shortness of breath
Nausea or vomiting
Abdominal pain or tenderness
Correct Answer : A,B,D,E
The correct answer is choice A, B, D and E. These are all signs and symptoms that may indicate worsening condition or preeclampsia in a client with gestational hypertension. Preeclampsia is a complication of pregnancy that is marked by high blood pressure and presence of proteins in urine.
Choice C is wrong because chest pain or shortness of breath are not typical symptoms of preeclampsia, but they may indicate other serious conditions such as heart problems or pulmonary edema.
If a client with gestational hypertension experiences these symptoms, they should seek immediate medical attention.
Normal ranges for blood pressure and proteinuria are:
• Blood pressure: less than 140/90 mm Hg.
• Proteinuria: less than 300 mg in a 24-hour urine collection or less than 30 mg/dL in a random urine sample.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
The correct answer is choice D) Level of consciousness and reflexes.This is because magnesium sulfate can cause toxicity and affect the central nervous system, leading to decreased level of consciousness and loss of reflexes.These are signs that the dose of magnesium sulfate should be reduced or stopped.
The nurse should prioritize assessing these parameters to prevent seizures and avoid magnesium toxicity.
Choice A) Respiratory rate and depth is wrong because magnesium sulfate can also cause respiratory depression, but this is a less common and less sensitive indicator of toxicity than level of consciousness and reflexes.
Choice B) Urine output and color is wrong because magnesium sulfate can also cause renal impairment, but this is not directly related to preventing seizures.However, urine output should be monitored to ensure adequate hydration and renal function.
Choice C) Blood pressure and heart rate is wrong because magnesium sulfate can also cause hypotension and bradycardia, but these are not the primary goals of therapy.Blood pressure and heart rate should be monitored to assess the severity of preeclampsia and the response to antihypertensive medications.
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