A nurse in a provider's office is reinforcing teaching about home care with a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching?
Perform daily fetal movement counts.
Limit fluid intake to 1,000 mL/day.
Limit sodium intake to 2,000 mg/day.
Rest in bed in the supine position.
The Correct Answer is A
Choice A rationale:
The nurse should include teaching the client to perform daily fetal movement counts because it is an essential aspect of monitoring the baby's well-being and assessing fetal distress. Fetal movement counts help the client become familiar with their baby's normal patterns of movement, allowing them to detect any changes or decreased movements promptly. This can be crucial in identifying potential issues with the baby's health and seeking timely medical attention.
Choice B rationale:
The nurse should not advise limiting fluid intake to 1,000 mL/day for a client with mild preeclampsia. Adequate hydration is important during pregnancy, and excessive fluid restriction can lead to dehydration, which is harmful to both the mother and the baby. Preeclampsia can cause fluid retention and high blood pressure, but complete fluid restriction is not the appropriate approach for managing the condition.
Choice C rationale:
The nurse should not suggest limiting sodium intake to 2,000 mg/day for a client with mild preeclampsia. While reducing sodium intake can be beneficial for some individuals with hypertension, it is not the primary focus in managing mild preeclampsia. The mainstay of treatment for mild preeclampsia typically involves close monitoring, rest, and potential medications to control blood pressure if necessary.
Choice D rationale:
The nurse should not recommend that the client rest in bed in the supine position. During pregnancy, especially with preeclampsia, lying flat on the back (supine position) can lead to a condition called supine hypotensive syndrome. This occurs when the weight of the uterus presses on the vena cava, reducing blood flow back to the heart and potentially causing a drop in blood pressure and decreased blood flow to the baby.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Excessive uterine enlargement. Rationale: The nurse should monitor the client for excessive uterine enlargement, as a hydatidiform mole is a rare condition in pregnancy where abnormal placental tissue forms instead of a fetus. This abnormal growth can lead to uterine enlargement beyond the expected size for gestational age.
Choice B rationale:
Rapidly dropping human chorionic gonadotropin (hCG) levels. Rationale: The nurse should also monitor the client's hCG levels. In a normal pregnancy, hCG levels typically rise steadily during the early stages. However, in the case of a hydatidiform mole, hCG levels may either plateau or drop rapidly due to the abnormal placental growth.
Choice C rationale:
Fetal heart rate irregularities. Rationale: Although a hydatidiform mole does not involve a viable fetus, the nurse should still assess for fetal heart rate irregularities. In some rare cases, the presence of abnormal placental tissue can cause confusion in the diagnosis, and there may be coexisting fetal development. Fetal heart rate irregularities may indicate potential complications.
Choice D rationale:
Whitish vaginal discharge. Rationale: Whitish vaginal discharge is not typically associated with a hydatidiform mole. Instead, this finding is more commonly seen in other vaginal infections or conditions unrelated to a molar pregnancy. The nurse should be cautious not to misinterpret this symptom as a definitive sign of a hydatidiform mole.
Correct Answer is D
Explanation
Choice A rationale:
The nurse should not advise the client to take deep, cleansing breaths before and after each contraction because it can interfere with the natural urge to push and may not be effective in helping with the labor process. When a client feels the urge to push, it is essential to work with their body's natural instincts.
Choice B rationale:
Instructing the client to hold their breath and push while counting to ten is not recommended. This Valsalva manoeuvre can cause a sudden increase in intra-abdominal pressure, which may reduce blood flow to the heart and brain and may be harmful to both the client and the baby. It's crucial to promote safe pushing techniques during labor.
Choice C rationale:
The instruction to push continuously throughout the entire contraction is also not ideal. Pushing continuously can lead to exhaustion and decrease the effectiveness of each push. It's essential to guide the client on when and how to push effectively to prevent unnecessary fatigue.
Choice D rationale:
The correct instruction is to let the client know when to push according to their contractions. The urge to push is a natural reflex that signifies the baby's descent into the birth canal. The nurse should encourage the client to listen to their body and push when they feel the urge during the contractions. This approach optimizes the client's efforts and conserves their energy for delivery.
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