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.
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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Related Questions
Correct Answer is D
Explanation
Explanation:
A. Expecting fathers to participate in the labor experience:
In many cultures, the involvement of fathers in the labor and childbirth experience is encouraged and valued as it promotes family bonding and support. However, cultural sensitivity requires recognizing that family dynamics and expectations can vary widely across cultures. Some cultures may prioritize the presence of female family members or may have specific rituals or traditions related to childbirth that may or may not involve fathers. Being culturally sensitive in this context means respecting and accommodating the preferences and traditions of each family rather than assuming a one-size-fits-all approach.
B. Using hand signs to communicate:
Using hand signs or gestures can be an effective communication strategy, especially when there are language barriers. It can help bridge communication gaps and enhance understanding between healthcare providers and clients from diverse cultural backgrounds. However, cultural sensitivity also involves recognizing that communication goes beyond language and includes understanding cultural norms, beliefs, and non-verbal cues that may vary across cultures. Therefore, while using hand signs can be helpful, it should be complemented by a broader understanding of cultural communication styles.
C. Including the use of MyPlate in nutrition teaching:
MyPlate is a visual tool used in nutrition education to promote healthy eating habits by illustrating recommended food portions from various food groups. While using MyPlate can be a valuable resource in nutrition teaching, cultural sensitivity in nutrition education requires consideration of cultural dietary practices, preferences, taboos, and traditional foods specific to each client's cultural background. It's important to tailor nutrition education to align with cultural norms and values related to food and eating habits to promote culturally appropriate and effective health education.
D. Assessing health beliefs and practices before health teaching:
This option reflects a crucial aspect of cultural sensitivity in healthcare. Assessing a client's health beliefs, values, practices, and cultural background before initiating health teaching allows healthcare providers to tailor their approach to meet the unique needs, preferences, and cultural context of each client. Understanding cultural perspectives on health and wellness enables providers to deliver more effective and culturally appropriate care, promote better communication, build trust, and enhance health outcomes.
Correct Answer is C
Explanation
Explanation:
A. Pattern of contractions: While the pattern of contractions is important in assessing labor progress, it alone may not differentiate between true labor and false labor (also known as Braxton Hicks contractions). True labor contractions typically become longer, stronger, and more frequent over time, but other factors must also be considered to confirm true labor.
B. Rupture of the membranes: Rupture of the membranes (water breaking) can occur during both true labor and false labor. However, it is not a definitive sign of true labor on its own, as it can also happen spontaneously or due to other reasons.
C. Changes in the cervix: This is the correct answer. True labor is characterized by progressive changes in the cervix, including effacement (thinning) and dilation (opening). These changes can be confirmed through a cervical examination performed by a healthcare provider.
D. Station of the presenting part: The station of the presenting part refers to the position of the baby's head in relation to the mother's pelvis. While the station can provide information about the progress of labor, it is not a specific sign of true labor by itself.
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