# Stage 4 — Generate solutions. Which interventions belong in the immediate plan of care? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568579&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

Stage 4 — Generate solutions. Which interventions belong in the immediate plan of care? Select all that apply.

1Pad side rails and keep suction and oxygen available
2Administer prescribed magnesium sulfate and monitor respirations, deep-tendon reflexes, and urine output
3Administer the prescribed urgent antihypertensive and recheck blood pressure
4Continue fetal monitoring and prepare for delivery after maternal stabilization
5Encourage hallway ambulation to reduce edema
6Maintain a low-stimulation environment and perform frequent neurologic and laboratory reassessment
7Delay treatment until a 24-hour urine collection is completed
8Give a rapid 2-liter crystalloid bolus without assessing pulmonary status

## Explanation

The plan addresses seizure prevention, severe hypertension, maternal-fetal surveillance, and timely delivery preparation. Ambulation, diagnostic delay, and an unassessed large fluid bolus are unsafe in an unstable client at risk for pulmonary edema.

## In-depth explanation

Quick answer
Use seizure precautions, monitored magnesium, urgent blood-pressure treatment, continuous fetal surveillance, frequent reassessment, and delivery preparation.

Why this is correct
Each selected action targets a current threat: seizure, stroke, organ deterioration, or fetal compromise. Maternal stabilization and delivery planning occur in parallel rather than as competing tasks.

Easy analogy or mental picture
Think of a two-patient safety bundle with one shared clock: protect the mother's brain and circulation while continuously checking the fetus and preparing the next definitive step.

Memory hook
Seizure, pressure, fetus, labs, delivery.

NCLEX decision rule
When severe preeclampsia is confirmed, bundle stabilization and maternal-fetal surveillance; avoid delays and unassessed fluids.

Why the other choices are wrong
Ambulation does not treat the emergency. A 24-hour urine collection is not a reason to delay treatment, and a large rapid fluid bolus may worsen pulmonary edema risk.

References
1ACOG: Preeclampsia and High Blood Pressure During PregnancySevere features, maternal-fetal deterioration, hospitalization, and delivery planning
2ACOG Practice Bulletin 222: Gestational Hypertension and PreeclampsiaUrgent blood-pressure control, magnesium monitoring, and severe-feature management; reaffirmed 2026

## Clinical scenario

Case update
The obstetric team confirms severe preeclampsia with HELLP features and enters emergency stabilization and delivery-preparation orders.

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