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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
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