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NurseDive Free Nursing Practice Question
A nurse is caring for a client with gestational hypertension who is at risk for developing preeclampsia.
Which of the following interventions should the nurse implement to prevent this complication? (Select all that apply.).
A. Encourage bed rest in a dark and quiet environment
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
B. Administer corticosteroids as prescribed
Corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
C. Monitor fetal heart rate and movement
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
D. Assess for headache, visual changes and epigastric pain
These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
E. Provide a diet high in protein and low in carbohydrates
A diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia. A balanced diet with adequate calcium, magnesium and antioxidants is advised.
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Full Explanation
The correct answer is choice A, C and D. These interventions can help prevent or delay the development of preeclampsia by reducing blood pressure, monitoring fetal well-being and assessing for signs of worsening condition.
Choice B is wrong because corticosteroids are not used to prevent preeclampsia, but to enhance fetal lung maturity in case of preterm delivery.
Choice E is wrong because a diet high in protein and low in carbohydrates is not recommended for gestational hypertension or preeclampsia. A balanced diet with adequate calcium, magnesium and antioxidants is advised.
Similar Questions
A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with severe preeclampsia who is in labor.
Which of the following findings would indicate that the therapy is effective?
A. The client’s blood pressure is within normal range
The client’s blood pressure may not normalize even with magnesium sulfate therapy. Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure.Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
B. The client’s urine output is at least 30 mL/hr
This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
C. The client’s deep tendon reflexes are 2+
The client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant
D. The client’s respiratory rate is above 16 breaths/min
The client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
Full Explanation
The correct answer is choice B. The client’s urine output is at least 30 mL/hr. This indicates that the therapy is effective because magnesium sulfate can cause renal impairment and fluid retention, which can worsen the condition of preeclampsia.
A normal urine output is a sign that the kidneys are functioning well and that the fluid balance is maintained.
Choice A is wrong because the client’s blood pressure may not normalize even with magnesium sulfate therapy.
Magnesium sulfate is mainly used to prevent seizures, not to lower blood pressure. Other antihypertensive medications may be needed to control blood pressure in severe preeclampsia.
Choice C is wrong because the client’s deep tendon reflexes are expected to decrease with magnesium sulfate therapy, as it is a central nervous system depressant.
A normal reflex response is 2+, but a lower response (1+ or 0) may indicate magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.
Choice D is wrong because the client’s respiratory rate should be monitored closely with magnesium sulfate therapy, as it can also cause respiratory depression.
A normal respiratory rate is 12 to 20 breaths per minute, but a lower rate (less than 12) may indicate magnesium toxicity, which requires immediate treatment with calcium gluconate.
A nurse is reviewing the risk factors for gestational hypertension with a group of pregnant clients at a prenatal clinic.
Which of the following factors should the nurse include? (Select all that apply.).
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
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.
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.
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.
E. African American race
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.
Full 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.
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?
A. Administer the medication over 30 min using an infusion pump
Shorter infusion time may increase the risk of adverse effects.
B. Place the client in a supine position with a wedge under the right hip
The client should be placed in a lateral position to improve uteroplacental perfusion and reduce the risk of aspiration.
C. Monitor the client’s blood pressure every 15 min during the infusion
The client’s blood pressure should be monitored every 5 minutes during the infusion, not every 15 minutes.
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.
Full 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.