A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?

Monitor blood pressure pulse, and respirations every 4 hour

Keep an airway at the bedside

Allow liberal family visitation

Assess temperature every hour

Answer and Explanation

The Correct Answer is B

A. Monitor blood pressure, pulse, and respirations every 4 hours: Monitoring vital signs is important, especially in a client with eclampsia. However, the frequency of monitoring may need to be increased, particularly if the client's condition is unstable.

B. Keep an airway at the bedside: This is a crucial intervention. Eclampsia can lead to seizures, and having airway management equipment readily available is essential to ensure the client's safety during and after a seizure.

C. Allow liberal family visitation: While family support is important, the priority in eclampsia management is the safety and well-being of the client. Family visitation should be allowed, but it may need to be balanced with the need for a controlled and safe environment.

D. Assess temperature every hour: While monitoring temperature is a part of routine care, it may not be the highest priority in the context of eclampsia. Monitoring for signs of imminent seizure activity and maintaining a safe environment take precedence.

Preeclampsia & eclampsia: Video, Anatomy & Definition | Osmosis

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Correct Answer is C

Explanation

A. Schedule an appointment for the client with the diabetic nurse educator:
This could be a helpful action. The diabetic nurse educator can provide valuable support and education on managing insulin needs during breastfeeding.

B. Counsel her to increase her caloric intake:
While adequate nutrition is essential, increasing caloric intake may not be the primary factor affecting insulin needs. It's important to consider the specific needs of the client, and any adjustments to insulin should be made based on careful monitoring.

C. Inform her that a decreased need for insulin occurs while breastfeeding:
This is accurate information. Breastfeeding can lead to a decreased need for insulin in some individuals. The nurse should provide education on this aspect of managing diabetes during breastfeeding.

D. Advise the client to breastfeed more frequently:
While breastfeeding frequency can impact insulin needs, it's essential to consider the overall picture. Simply increasing breastfeeding frequency may not be the only factor affecting insulin requirements.

A. Describe genetic testing protocols B. Discontinue the methadone right away C. Sign up for group therapy sessions D. Start a prenatal care plan as soon as possible

Correct Answer is D

Explanation

A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.

B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.

C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.

D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.

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A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing Which intervention should the nurse plan to include in this client's nursing care plan?

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Naxlex Comprehensive Predictor Exams

A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?

Correct Answer is C

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Correct Answer is D

Explanation

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