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 A

Explanation

Choice A rationale:

This finding may indicate a neurological problem or an issue with the baby's ability to feed, which can lead to inadequate nutrition and hydration. It's essential for the newborn to establish good feeding patterns early on

Choice B rationale:

Blue coloring of the hands and feet, also known as acrocyanosis, is a common and normal finding in newborns. It results from the immaturity of the peripheral circulation and usually resolves on its own without any intervention.

Choice C rationale:

A soft, edematous area on the scalp, also known as caput succedaneum, is a common finding following vacuum-assisted delivery and typically resolves without intervention.

Choice D rationale:

Facial edema is another common finding in newborns, especially after vacuum-assisted deliveries. It is typically a transient and self-resolving condition that does not require immediate intervention or reporting to the provider.

A. Encourage the mother to breastfeed the newborn. B. Gavage feed 60 mL (2 oz) of glucose water. C. Administer 10 mL of D5W via IV. D. Recheck the glucose level in 2 hr.

Correct Answer is A

Explanation

Choice A reason:

Breastfeeding is the recommended first line of action for a newborn with a blood glucose level of 40 mg/dL, which is on the lower end of the normal range (normal range: 40-60 mg/dL for a newborn). Breast milk provides a natural source of glucose and other nutrients essential for the newborn's growth and development. It also facilitates bonding and has immunological benefits. Early initiation of breastfeeding helps to stabilize the blood glucose levels naturally.

Choice B reason:

Gavage feeding 60 mL of glucose water is not the first choice for managing borderline low blood glucose levels in a newborn. This method is typically reserved for infants who cannot feed orally due to medical conditions or prematurity. It is an invasive procedure and can be stressful for the newborn.

Choice C reason:

Administering 10 mL of D5W (5% dextrose in water) via IV is a treatment for hypoglycemia (low blood glucose levels), not for borderline low levels like 40 mg/dL. This intervention is usually considered when blood glucose levels are significantly lower than the normal range and the infant is symptomatic or unable to tolerate oral feedings.

Choice D reason:

Rechecking the glucose level in 2 hours is a passive approach and may not be appropriate for a newborn with a blood glucose level of 40 mg/dL. Immediate action, such as feeding, is preferred to prevent potential hypoglycemia and its associated risks.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a newborn who has a blood glucose level of 40 mg/dL. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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