HESI Maternity 55 Questions Related

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What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

  • A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
  • B. Risk for altered gas exchange.
  • C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
  • D. Risk for increased cardiac output, related to the use of antihypertensive drugs.
Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.