Nokea
A nurse is caring for a client who is G1P0 and 36 weeks gestation who has been diagnosed with severe pre-eclampsia. Her blood pressure is 165/110. The physician has ordered hydralazine. The nurse knows she should do which of the following when administering this medication?
Correct Answer: B
Rationale: The correct answer is B. Getting baseline blood pressure and pulse and monitoring frequently during administration is crucial because hydralazine is a potent antihypertensive medication that can cause significant drops in blood pressure. Monitoring allows for early detection of hypotension or adverse reactions.
A is incorrect because positioning the client supine with the head of the bed elevated 30 degrees is not specific to the administration of hydralazine for pre-eclampsia.
C is incorrect because administering medication every 5 minutes until blood pressure is stabilized is not a standard protocol for hydralazine administration; it should be given as per physician's orders with appropriate monitoring.
D is incorrect because informing the client about a positive direct Coombs test result is not relevant to the administration of hydralazine; this is more pertinent to medications that can cause hemolytic anemia.