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
Fresh cabbage leaves have been traditionally used as a home remedy to help alleviate pain and discomfort associated with breast engorgement. The coolness of the cabbage leaves can provide a soothing effect, and they may also have anti-inflammatory properties that help reduce swelling. However, it is important to note that this should be used as a complementary measure and not a substitute for medical treatment or advice if the engorgement is severe or persistent.
Correct Answer is C
Explanation
Choice A rationale:
Fentanyl is an opioid analgesic and is not used to counteract the effects of meperidine in the newborn. Both fentanyl and meperidine are opioids, and using fentanyl in this context would not counteract the effects of meperidine.
Choice B rationale:
Flumazenil is a medication used to reverse the effects of benzodiazepines, not opioids like meperidine. It is not appropriate for countering the effects of meperidine in the newborn.
Choice C rationale:
Naloxone is an opioid antagonist that can reverse the effects of opioids like meperidine. When a newborn has been exposed to opioids during labor, such as meperidine given to the mother, there is a risk of respiratory depression in the newborn. Naloxone can quickly reverse this effect and restore normal respiratory function.
Choice D rationale:
Benztropine is an anticholinergic medication used to treat side effects of antipsychotic drugs and is not relevant in this situation. It would not counteract the effects of meperidine on the newborn.
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