Difficulty: Medium
Average Score: 64%
Simulated
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/hour. The nurse has determined the priority nursing diagnosis to be: risk for central nervous system injury related to hypertension, edema of cerebrum. To maintain safety for this client, the nurse should:
Correct answer
C
Rationale
Monitoring signs of CNS irritability such as reflexes, clonus, visual disturbances, and headache helps detect worsening preeclampsia.