According to agency policy, the perinatal nurse provides the following intrapartal nursing care for the patient with preeclampsia:

a. Take the patient's blood pressure every 6 hours
b. Encourage the patient to rest on her back
c. Notify the physician of urine output greater than 30 mL/hr
d. Administer magnesium sulfate according to agency policy


ANS: d
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a. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The blood pressure is taken every 1 hour or more frequently according to physician orders or institutional protocol.
b. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The patient should be encouraged to assume a side-lying position to enhance uterine perfusion.
c. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. A urine output less than 30 mL/hr is indicative of oliguria, and the physician must be notified.
d. The nurse is the manager of care for the woman with preeclampsia during the intrapartal period. Careful assessments are critical. The nurse administers medications as ordered and should adhere to hospital protocol for a magnesium sulfate infusion.

Nursing

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