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 C

Explanation

Choice A rationale:

This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.

Choice B rationale:

This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.

Choice C rationale:

This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.

Choice D rationale:

This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.

A. Bradycardia. B. Flushed face. C. Hypotension. D. Polyuria.

Correct Answer is C

Explanation

Choice C rationale:

Hypotension is a finding that indicates the client is experiencing decreased cardiac output. Excessive vaginal bleeding can lead to hypovolemia, reducing the volume of blood pumped by the heart and resulting in decreased cardiac output. The body responds to hypovolemia and decreased cardiac output by trying to maintain blood pressure, which leads to hypotension.

Choice A rationale:

Bradycardia is not a finding indicating decreased cardiac output in this scenario. While bradycardia (abnormally slow heart rate) can be associated with decreased cardiac output in certain situations, it is not the primary finding in a postpartum client experiencing excessive vaginal bleeding.

Choice B rationale:

A flushed face is not an indicator of decreased cardiac output. A flushed face may result from various factors such as fever or emotional stress, but it is not directly related to cardiac output.

Choice D rationale:

Polyuria (excessive urination) is not an indicator of decreased cardiac output. Polyuria may occur due to factors like diuresis or increased fluid intake but is not directly related to cardiac output in the context of excessive vaginal bleeding.

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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 has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?

Correct Answer is C

Explanation

A nurse is assessing a client who gave birth 12 hr ago and is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?

Correct Answer is C

Explanation

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