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 is the correct choice. The American Academy of Pediatrics (AAP) recommends keeping children in a rear-facing car seat until they reach the age of 2 or until they reach the maximum weight and height allowed by the car seat's manufacturer. This is because rear- facing seats provide better support for a baby's head, neck, and spine during a crash, reducing the risk of injury.

Choice B rationale:

Placing the retainer clip over the upper part of the baby's abdomen is incorrect and potentially dangerous. The retainer clip should be positioned at armpit level to secure the harness straps properly.

Choice C rationale:

Placing the baby in the car seat at a 90-degree angle is not necessary. The car seat should be installed according to the manufacturer's instructions, and the angle will vary based on the specific car seat model.

Choice D rationale:

Placing the shoulder harness straps in the slots an inch above the baby's shoulders is incorrect. The straps should be positioned at or below the baby's shoulders for rear-facing car seats and at or above the shoulders for forward-facing seats.

A. Bladder distention. B. Pulse rate. C. Respiratory rate. D. Color of lochia.

Correct Answer is B

Explanation

Choice A rationale:

Assessing for bladder distention is important for postpartum clients, especially those who have undergone perineal trauma during childbirth. However, it is not the priority assessment during a sitz bath. The sitz bath is usually done to promote healing and comfort, and monitoring pulse rate takes precedence to identify any adverse reactions.

Choice B rationale:

Pulse rate should be the priority assessment during a sitz bath for a postpartum client. Sitz baths can cause vasodilation, leading to a potential drop in blood pressure, increased heart rate, or dizziness. Monitoring the pulse rate helps identify any cardiovascular changes or adverse reactions.

Choice C rationale:

Respiratory rate is not the priority assessment during a sitz bath. It is essential to monitor, but it is less likely to be affected directly by the sitz bath compared to the pulse rate and cardiovascular changes.

Choice D rationale:

Monitoring the color of lochia is essential for assessing postpartum bleeding and uterine healing. However, during a sitz bath, the priority assessment should be focused on cardiovascular changes and any adverse reactions the client might experience.

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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

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