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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 B

Explanation

Explanation:

To calculate the estimated date of delivery (EDD) based on the client's last menstrual period (LMP), the nurse can use Naegele's rule. Naegele's rule calculates the EDD by adding 7 days to the first day of the LMP, subtracting 3 months, and then adding 1 year.

Given the client's last menstrual period was July 4, 2020, we can apply Naegele's rule:

Add 7 days to July 4, 2020: July 11, 2020

Subtract 3 months: April 11, 2020

Add 1 year: April 11, 2021

Therefore, the appropriate response by the nurse is:

B. April 11, 2021

A. Gradual lordosis B. Decreased mobility of pelvic joints C. Posterior neck flexion D. Increased abdominal muscle tone

Correct Answer is A

Explanation

Explanation:

A. Gradual lordosis:

Gradual lordosis refers to an increased curvature of the lower spine (lumbar region). During pregnancy, as the uterus enlarges and the center of gravity shifts forward, the body compensates by increasing the curve of the lower spine. This change helps maintain balance and stability as the woman's abdomen expands due to the growing fetus. It is considered a normal adaptation to pregnancy and is often observed in the third trimester.

B. Decreased mobility of pelvic joints:

This statement is incorrect in the context of pregnancy. In fact, during pregnancy, the hormone relaxin is released, which causes relaxation and increased mobility of pelvic joints. This increased mobility is important for allowing the pelvis to expand during childbirth, facilitating the passage of the baby through the birth canal. Therefore, decreased mobility of pelvic joints is not an expected physiologic change during pregnancy.

C. Posterior neck flexion:

Posterior neck flexion refers to bending the neck backward. This is not typically associated with pregnancy-related changes. Pregnancy-related changes mainly affect the abdominal area, lower back, and pelvis rather than the neck. Therefore, posterior neck flexion is not an expected physiologic change during pregnancy.

D. Increased abdominal muscle tone:

During pregnancy, the abdominal muscles often experience stretching and relaxation rather than increased tone. This is because the growing uterus and fetus require more space, leading to abdominal wall stretching. The abdominal muscles may become less toned and more relaxed to accommodate the expanding uterus. Therefore, increased abdominal muscle tone is not an expected physiologic change during pregnancy.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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