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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Evaluate neurologic status every 8 hr.

Provide a dark, quiet environment.

Administer magnesium sulfate IV.

Ensure that calcium gluconate is readily available.

Assess respiratory status every 4 hr.

Answer and Explanation

Correct Answer : B,C,D

Explanation:

A. Evaluate neurologic status every 8 hr.

While monitoring neurologic status is important in clients with severe gestational hypertension to assess for signs of impending eclampsia (seizures), more frequent monitoring is typically required, such as every 4 hours or even more frequently depending on the severity of the condition. Therefore, evaluating neurologic status every 8 hours is not sufficient for this client.

B. Provide a dark, quiet environment.

Creating a calm and low-stimulation environment helps to reduce the risk of seizures, which can be triggered by bright lights and loud noises in clients with severe gestational hypertension.

C. Administer magnesium sulfate IV.

Magnesium sulfate is commonly used to prevent seizures in clients with severe gestational hypertension (preeclampsia). It is a standard treatment to prevent eclampsia, a serious complication of preeclampsia characterized by seizures. Therefore, the nurse should expect to administer magnesium sulfate IV as part of the management plan for severe gestational hypertension.

D. Ensure that calcium gluconate is readily available.

Magnesium sulfate, while effective in preventing seizures, can lead to magnesium toxicity if levels become too high. Calcium gluconate is the antidote for magnesium sulfate toxicity. Therefore, the nurse should ensure that calcium gluconate is readily available to counteract any potential magnesium toxicity that may occur during magnesium sulfate administration.

E. Assess respiratory status every 4 hr.

Monitor and record vital signs (blood pressure, pulse, respirations, O2 saturation) every 1 hour x’s 8 hours after maintenance infusion is started and vital signs for bolus infusion are complete. If respiratory rate < 12 breaths/min, draw magnesium level, notify HCP, and observe closely.

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Correct Answer is A

Explanation

Explanation:

A. "This will occur between the fourth and fifth months of pregnancy."

This response is accurate and aligns with the typical timeframe for quickening, which is the first perception of fetal movements by the pregnant person. Quickening commonly occurs between the 16th and 20th week of pregnancy, corresponding to the fourth and fifth months. However, it's essential to note that the exact timing can vary from person to person and pregnancy to pregnancy.

B. "This will happen by the end of the first trimester of pregnancy."

This response is not entirely accurate. Quickening typically occurs later than the end of the first trimester. While some women, particularly those who have been pregnant before, may feel fetal movements toward the end of the first trimester, it's more common to experience quickening during the second trimester.

C. "This will happen once the uterus begins to rise out of the pelvis."

This response is not directly related to quickening. The rising of the uterus (fundus) out of the pelvic cavity is a physical change that occurs as the pregnancy progresses, but it doesn't signify the onset of fetal movements (quickening). Quickening is specifically about feeling the baby's movements, not the position of the uterus.

D. “This will occur during the last trimester of pregnancy."

This response is incorrect. Quickening typically occurs much earlier, specifically during the second trimester, around the 16th to 20th week of pregnancy. Waiting until the last trimester to feel fetal movements would be unusual and might prompt further evaluation or discussion with a healthcare provider.

A. Preparation for cesarean birth B. Initiation of pushing C. Examination to determine cervical status D. A magnesium sulfate infusion

Correct Answer is A

Explanation

Explanation:

A. Preparation for cesarean birth:

This is the correct choice. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. In cases of suspected placenta previa with significant bleeding, cesarean birth is the safest delivery option to minimize the risk of complications such as hemorrhage. Therefore, immediate preparation for cesarean birth is indicated to ensure the safety of both the mother and the baby.

B. Initiation of pushing:

Pushing or active pushing efforts are contraindicated in cases of suspected placenta previa with significant vaginal bleeding. Pushing can increase the risk of further placental detachment and exacerbate bleeding. It is crucial to avoid any actions that could worsen the bleeding or harm the mother and baby. Therefore, initiation of pushing is not appropriate in this situation.

C. Examination to determine cervical status:

While cervical examinations are important during labor to assess progress and determine readiness for delivery, they are not appropriate in cases of suspected placenta previa with active vaginal bleeding. Cervical examinations can potentially increase bleeding and should be avoided until the placental location and stability are assessed through ultrasound or other diagnostic methods. Therefore, examination to determine cervical status is not appropriate in this situation.

D. A magnesium sulfate infusion:

Magnesium sulfate infusion is not indicated for suspected placenta previa with significant vaginal bleeding. Magnesium sulfate is commonly used to prevent or manage preterm labor and certain hypertensive disorders during pregnancy but is not a treatment for placenta previa or its associated bleeding. Immediate preparation for cesarean birth is the priority in this situation to ensure the safety of the mother and baby. Therefore, a magnesium sulfate infusion is not appropriate in this situation.

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A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

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Correct Answer is A

Explanation

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Explanation

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