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 C
Explanation
Explanation:
A. Braxton Hicks contraction
Braxton Hicks contractions are often referred to as "practice" contractions and are common during pregnancy. They are typically irregular and do not cause cervical changes. While discomfort after an amniocentesis procedure can sometimes trigger Braxton Hicks contractions, they are not usually a cause for immediate concern unless they become frequent, intense, or are accompanied by other signs of preterm labor, such as regular contractions, lower back pain, pelvic pressure, or changes in vaginal discharge.
B. Amniotic fluid contains fetal urine
The presence of fetal urine in the amniotic fluid is a normal and expected process during pregnancy. Fetal urine production contributes to the volume and composition of amniotic fluid, helping maintain the environment in the uterus and supporting fetal development. This finding is not directly related to the client's discomfort after an amniocentesis procedure and is not a cause for immediate concern unless there are other complications or abnormalities related to the amniotic fluid composition.
C. Prolonged vaginal bleeding
Prolonged vaginal bleeding after an amniocentesis procedure is a significant finding that requires immediate attention. While some spotting or mild bleeding can occur after the procedure, prolonged or significant bleeding may indicate complications such as uterine injury, placental abruption, or other issues that need urgent assessment and intervention by healthcare providers.
D. Lab results reveal abnormal chromosome cells
Abnormal chromosome cells found in the amniotic fluid sample obtained during amniocentesis may indicate genetic abnormalities or conditions in the fetus. While this finding is significant and requires follow-up and further evaluation, it is not an immediate concern in terms of the client's discomfort or the need for priority action by the nurse unless it is associated with other urgent clinical signs or symptoms.
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.
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