A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
Continuous fetal monitoring
Ambulate to induce labor
Obtain a daily weight
Assess deep tendon reflexes every hour
The Correct Answer is B
Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.
Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.
Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.
Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. No special treatment is necessary.
Choice A reason: Prone positioning is not typically recommended for a fractured clavicle in infants. It does not facilitate bone alignment in the case of clavicle fractures and is not part of standard care.
Choice B reason: This is the correct choice because clavicle fractures in newborns generally heal on their own without the need for special treatment. Parents may be instructed to pin the child’s sleeve to the front of their clothing to avoid moving the arm while it heals, but beyond gentle handling, no other special treatment is necessary. In most cases, clavicle fractures in newborns heal very quickly without any problems, and usually, no treatment is required.
Choice C reason: Immobilization and casting are not standard care for newborn clavicle fractures. These fractures typically heal without such interventions, and immobilization with a cast is not needed for these types of injuries in infants.
Choice D reason: While range-of-motion exercises might be beneficial later in the healing process, they are not the primary consideration immediately after the fracture occurs. The initial care plan focuses on gentle handling and comfort for the infant, not on exercises.
Correct Answer is D
Explanation
Choice A reason: Calcium carbonate is not the compound that the nurse should have readily available, as it is an antacid that neutralizes stomach acid and relieves heartburn. Calcium carbonate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice B reason: Potassium chloride is not the compound that the nurse should have readily available, as it is an electrolyte supplement that replenishes potassium levels and prevents hypokalemia. Potassium chloride is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice C reason: Ferrous sulfate is not the compound that the nurse should have readily available, as it is an iron supplement that prevents or treats iron deficiency anemia. Ferrous sulfate is not used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
Choice D reason: Calcium gluconate is the compound that the nurse should have readily available, as it is an antidote that reverses the effects of magnesium sulfate and restores calcium levels and neuromuscular function. Calcium gluconate is used to treat severe preeclampsia or magnesium sulfate toxicity, which are the conditions that the client may have.
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