The nurse is caring for a client who was diagnosed with pre-eclampsia prior to delivery. The nurse develops which of the following goals for this client? Select all that apply. Standard Text: Select all that apply

Question

1. Blood pressure will return to pre-labor levels within 1 hour of birth.
2. Proteinuria will decline prior to discharge.
3. Reflexes will remain at 2+ or above within 24 hours.
4. Edema will begin to decrease within 24 hours.
5. Will maintain a stable weight until discharged from the hospital.

Answer 1

1,2
Rationale: The client's blood pressure should return to pre-labor level within an hour of delivery, and should be monitored frequently (at least hourly) if it does not. Proteinuria will take time to subside, but should begin to decline by time of discharge. Reflexes should be less than 2+, and she should not have two beats of clonus with dorsiflexion. Edema should begin to subside within the first 12-24 hours, and weight should decline as a result.