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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 D

Explanation

Explanation:

A. Congenital heart defects:

Smoking during pregnancy has been linked to an increased risk of congenital heart defects in newborns. Maternal smoking can affect the development of the baby's heart, leading to structural abnormalities in the heart's formation. These defects can range from mild to severe and may require medical intervention after birth.

B. Hearing loss:

Although there is some evidence suggesting a possible association between maternal smoking and hearing problems in children, the link is not as well-established as other complications such as intrauterine growth restriction or congenital heart defects. More research is needed to confirm the direct impact of maternal smoking on hearing loss in newborns.

C. Type 1 diabetes mellitus:

Maternal smoking during pregnancy is not directly linked to an increased risk of Type 1 diabetes mellitus in newborns. Type 1 diabetes is an autoimmune condition that is not typically influenced by maternal smoking during pregnancy.

D. Intrauterine growth restriction (IUGR):

This is the correct choice. Smoking during pregnancy is a well-known risk factor for intrauterine growth restriction (IUGR). It can lead to inadequate fetal growth and lower birth weight than expected for gestational age due to restricted oxygen and nutrient supply to the fetus. Babies born with IUGR may experience various health issues and developmental challenges.

A. A client who is at 38 weeks of gestation and reports a cough and fever B. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who has missed a period and reports vaginal spotting

Correct Answer is A

Explanation

Explanation:

A. A client who is at 38 weeks of gestation and reports a cough and fever.

The client at 38 weeks of gestation with a cough and fever presents with symptoms that could indicate a potential infection, such as respiratory or urinary tract infection, which can be serious during pregnancy. Infections in late pregnancy can also increase the risk of complications for both the mother and the baby. Therefore, assessing this client first is crucial to evaluate and address any potential infection and prevent complications.

B. A client who is at 28 weeks of gestation and reports painless vaginal bleeding.

Painless vaginal bleeding can be a concern, especially in the second or third trimester, as it may indicate conditions such as placenta previa or placental abruption. However, since this client's bleeding is painless, it may not be an immediate emergency compared to the potential infection in option A.

C. A client who is at 14 weeks of gestation and reports nausea and vomiting.

Nausea and vomiting, commonly known as morning sickness, are common during early pregnancy. While these symptoms can be uncomfortable, they are typically not urgent unless they lead to dehydration or other complications, which would require assessment but may not be as urgent as a potential infection in option A.

D. A client who has missed a period and reports vaginal spotting.

Vaginal spotting can occur in early pregnancy and may or may not be concerning depending on the amount and frequency. Since this client has missed a period, it suggests early pregnancy, and spotting can be relatively common in early pregnancy without indicating a significant problem. However, assessment is still needed to rule out any potential complications.

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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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Explanation

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