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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 C

Explanation

Explanation:

A. "You will need to double your intake of iron during pregnancy."

This statement is not accurate. While iron needs do increase during pregnancy to support the increased blood volume and fetal development, the recommended increase is not necessarily a doubling of intake. Specific iron requirements can vary based on individual factors, such as pre-pregnancy iron status and maternal health conditions.

B. "Prenatal vitamins will meet your need for increased vitamin D during pregnancy."

Prenatal vitamins typically contain some vitamin D, but they may not meet the increased need for vitamin D during pregnancy entirely, especially if the client has limited sun exposure or other risk factors for vitamin D deficiency. Additional sources of vitamin D, such as sunlight exposure and dietary sources, may be recommended.

C. "You will need to increase your calcium intake during breastfeeding."

This statement is correct. During breastfeeding, calcium requirements increase to support milk production and the maintenance of maternal bone health. Adequate calcium intake is important for both the mother and the growing infant.

D. "Vitamin E requirements decline during pregnancy due to the increase in body fat."

This statement is not accurate. Vitamin E requirements do not necessarily decline during pregnancy because of an increase in body fat. Vitamin E is still essential during pregnancy for its antioxidant properties and role in fetal development.

A. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." B. "It occurs during the first trimester and near the end of the pregnancy." C. "There is no way to predict how long it will last in each individual client." D. "It's a minor inconvenience, which you should ignore."

Correct Answer is A

Explanation

Explanation:

A. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone."

This response is accurate and informative. It explains that urinary frequency is a common symptom during early pregnancy due to hormonal changes and pressure on the bladder. It also provides a general timeline by stating that, in most cases, urinary frequency improves by the 12th week as the uterus rises out of the pelvis. Additionally, it mentions that poor bladder tone can contribute to ongoing urinary frequency, acknowledging individual differences.

B. "It occurs during the first trimester and near the end of the pregnancy."

This response is not accurate. While urinary frequency is common during the first trimester due to hormonal changes and pressure on the bladder, it typically improves rather than occurring again near the end of pregnancy. Mentioning both the first trimester and near the end of pregnancy could be confusing and misleading for the client.

C. "There is no way to predict how long it will last in each individual client."

While there can be individual variations in how long urinary frequency lasts during pregnancy, there are general trends and common timelines for this symptom. This response may be seen as somewhat dismissive or uninformative since it does not provide any guidance or context for the client's question.

D. "It's a minor inconvenience, which you should ignore."

This response is not appropriate as it dismisses the client's concerns about urinary frequency. While urinary frequency is a common symptom during pregnancy, it can still be uncomfortable for some individuals, and healthcare providers should acknowledge and address their concerns rather than suggesting they ignore them.

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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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