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.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Premature ovarian failure affects the ovaries and leads to early menopause, resulting in the loss of the woman's reproductive ability. This condition can cause infertility due to the depletion or dysfunction of eggs in the ovaries, hindering conception.
Choice B rationale:
Renal calculi (kidney stones) do not directly impact fertility. It is a condition unrelated to the reproductive system.
Choice C rationale:
Dysmenorrhea refers to painful menstruation and, while it can be uncomfortable, it does not necessarily affect fertility.
Choice D rationale:
Recurrent urinary tract infections may be a concern for overall health but do not necessarily directly impact fertility unless there are severe complications. They are unrelated to infertility assessment.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include in the teaching that a yearly Pap test is recommended until 70 years of age. This recommendation is based on current guidelines, which state that women should start getting Pap tests at age 21 and continue every three years until they reach the age of 65. However, if they undergo HPV testing along with the Pap test and have consistently negative results, they can extend the screening interval to every five years. After the age of 65, if they have had regular screenings with normal results, they may discontinue Pap testing.
Therefore, it is important to clarify the appropriate age range for the Pap test to ensure the client's understanding and compliance with screening guidelines.
Choice B rationale:
The nurse should not include choice B, "Pap tests are discontinued following removal of the ovaries,” in the teaching. The presence or absence of ovaries does not affect the need for Pap testing. The Pap test is primarily used to screen for cervical cancer, and its necessity is determined based on age and previous screening results, not on ovarian status.
Choice C rationale:
The nurse should not include choice C, "Avoid having sexual intercourse for 24 hours prior to the Pap test,” in the teaching. While it is generally recommended to avoid vaginal intercourse and douching for at least 24 hours before a Pap test, it is not the most crucial information to include in this context. The primary teaching point should focus on the recommended age range and frequency of Pap tests.
Choice D rationale:
The nurse should not include choice D, "Viral infections can be detected by a Pap test,” in the teaching. The Pap test is not designed to detect viral infections. Instead, it is used to detect abnormal cervical cells, which may indicate pre-cancerous or cancerous changes.
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