A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
Restrict protein intake to less than 40 g/day.
Initiate seizure precautions for the client.
Initiate an infusion of 0.9% sodium chloride at 150 ml/hr.
Encourage the client to ambulate twice per day.
The Correct Answer is B
Choice A rationale:
Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.
Choice B rationale:
Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.
Choice C rationale:
Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.
Choice D rationale:
Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.
Choice B rationale:
Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.
Choice C rationale:
Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.
Choice D rationale:
Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.
Correct Answer is C
Explanation
Choice A rationale:
Digoxin is a cardiac glycoside and is primarily used in the management of certain heart conditions, such as heart failure and atrial fibrillation. It is not indicated for hyperemesis gravidarum, which is severe and persistent vomiting during pregnancy.
Choice B rationale:
Calcium gluconate is a mineral supplement used to treat calcium deficiencies. It is not a standard treatment for hyperemesis gravidarum.
Choice C rationale:
Vitamin Bs (B6 and B12) are commonly used to manage hyperemesis gravidarum. Vitamin B6, also known as pyridoxine, has been shown to alleviate nausea and vomiting during pregnancy. Vitamin B12 may also be administered to help manage symptoms. Both vitamins are safe to use during pregnancy.
Choice D rationale:
Propranolol is a beta-blocker used to treat high blood pressure, heart conditions, and migraines. It is not recommended for managing hyperemesis gravidarum and is generally avoided during pregnancy due to potential risks to the developing fetus.
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