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 D
Explanation
Choice A rationale:
The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.
Choice B rationale:
Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.
Choice C rationale:
Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.
Choice D rationale:
Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.
Correct Answer is B
Explanation
The correct answer is choice B. Assure the client that the score is within the expected range.
Choice A rationale:
Administering oxygen and notifying the provider is not necessary for a biophysical profile (BPP) score of 10. A score of 10 indicates that the fetus is well-oxygenated and there are no signs of distress.
Choice B rationale:
A BPP score of 10 is considered normal and reassuring, indicating that the fetus is well-oxygenated and there are no signs of distress. Therefore, the nurse should assure the client that the score is within the expected range.
Choice C rationale:
Offering the client orange juice and repeating the assessment in 1 hour is not necessary for a BPP score of 10. This action might be considered if the score were lower and there was a need to reassess fetal well-being.
Choice D rationale:
Assisting the client into a side-lying position is not required for a BPP score of 10. This position is typically recommended to improve uteroplacental blood flow in cases of fetal distress or lower BPP scores.
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