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. Prepare the abdominal and perineal areas: While preparing the abdominal and perineal areas may be necessary for potential interventions, such as a cesarean section or vaginal examination, it is not the priority at this moment.
B. Witness the signature for informed consent for surgery: Obtaining informed consent for surgery is important, especially if surgical intervention is anticipated. However, the priority in this case is to stabilize the client's condition and address the potential causes of painless, bright red vaginal bleeding.
C. Insert an indwelling urinary catheter: Inserting an indwelling urinary catheter may be beneficial for monitoring urinary output and assessing fluid status. However, it is not the immediate priority compared to addressing the client's vital signs and managing potential causes of bleeding.
D. Initiate IV access: This is the correct answer. Given the client's large amount of painless, bright red vaginal bleeding, the priority is to establish IV access to administer fluids and possibly blood products if there is evidence of hypovolemia or hemorrhage. IV access will also allow for the administration of medications or other interventions as needed.
Correct Answer is A
Explanation
Explanation:
A. Placenta previa: Placenta previa is a condition where the placenta partially or completely covers the cervix. Painless, bright red vaginal bleeding is a common symptom of placenta previa, especially in the third trimester. This bleeding occurs because the placental blood vessels are disrupted as the cervix begins to dilate or efface during pregnancy.
B. Abruptio placentae: Abruptio placentae is a condition where the placenta detaches from the uterine wall prematurely, leading to painful bleeding. However, the bleeding associated with abruptio placentae is typically dark red and accompanied by uterine pain or contractions. In the scenario described, the bleeding is painless, making abruptio placentae less likely.
C. Threatened abortion: Threatened abortion refers to vaginal bleeding during early pregnancy (before 20 weeks) that may or may not be accompanied by cramping or abdominal pain. It is not typically associated with painless, bright red bleeding at 36 weeks gestation.
D. Precipitous labor: Precipitous labor refers to a rapid labor and delivery process, often completing in less than three hours from onset of contractions to delivery. It is not related to painless, bright red vaginal bleeding.
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