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) 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.
Correct Answer is ["A","B","C","D"]
Explanation
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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