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.

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale:

This would be incorrect advice. Increasing dietary fiber is commonly recommended during pregnancy to prevent constipation, but it does not address stress incontinence.

Choice B rationale:

This is a correct choice. Kegel exercises are beneficial during pregnancy to strengthen the pelvic floor muscles, which can help manage stress incontinence.

Choice C rationale:

This would be incorrect advice. Restricting daily fluid intake during pregnancy is generally not recommended as it can lead to dehydration and is unlikely to improve stress incontinence.

Choice D rationale:

This is another correct choice. Caffeine is a bladder irritant and can worsen stress incontinence, so reducing caffeine intake can be helpful.

Choice E rationale:

This would be incorrect advice. Regular exercise during pregnancy is generally encouraged unless there are specific medical reasons to avoid it. Avoiding daily exercise is not the appropriate approach to manage stress incontinence.

A. "I will keep my baby's head elevated while he is feeding.” B. "I will allow my baby to burp several times during each feeding.” C. "I will tip the nipple so air is present as my baby sucks.” D. "My baby will have soft, formed yellow stools.”

Correct Answer is C

Explanation

The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:

The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.

Choice B rationale:

The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.

Choice C rationale:

Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.

Choice D Rationale:

Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is at 32 weeks of gestation and is experiencing stress incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

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Correct Answer is C

Explanation

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