A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)
Provide a dark, quiet environment.
Evaluate neurologic status every 12 hr.
Assess respiratory status every 8 hr.
Ensure that calcium gluconate is readily available.
Administer magnesium sulfate IV.
Correct Answer : A,D,E
Choice A reason: Providing a dark, quiet environment is an appropriate action for the nurse to implement, because it can help reduce the client's blood pressure and prevent seizures.
Choice B reason: Evaluating neurologic status every 12 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should assess the client's neurologic status every 2 to 4 hr, or more often if indicated, to detect signs of cerebral edema or eclampsia.
Choice C reason: Assessing respiratory status every 8 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should monitor the client's respiratory status every 1 to 2 hr, or more often if indicated, to detect signs of pulmonary edema or respiratory depression.
Choice D reason: Ensuring that calcium gluconate is readily available is an appropriate action for the nurse to implement, because it is the antidote for magnesium sulfate toxicity. The nurse should have calcium gluconate on hand and know how to administer it in case of an emergency.
Choice E reason: Administering magnesium sulfate IV is an appropriate action for the nurse to implement, because it is the drug of choice for preventing and treating seizures in clients with severe gestational hypertension. The nurse should follow the protocol for magnesium sulfate administration and monitor the client's vital signs, urine output, reflexes, and serum magnesium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This action is the first and most important intervention that the nurse should perform, as it can prevent or reduce the compression of the umbilical cord, which can cause fetal hypoxia, bradycardia, or death. The nurse should insert a gloved hand into the vagina and gently push the presenting part away from the cord, and maintain this position until the delivery.
Choice B reason: This action is not the first intervention that the nurse should perform, as it does not address the cause of the cord prolapse, which is the displacement of the cord below the presenting part. However, this action is helpful to prevent the drying and infection of the cord, and should be done after the first intervention.
Choice C reason: This action is not the first intervention that the nurse should perform, as it may not be effective or feasible depending on the stage of labor and the client's condition. However, this action is beneficial to reduce the pressure of the presenting part on the cord, and should be done after the first intervention.
Choice D reason: This action is not the first intervention that the nurse should perform, as it does not provide immediate relief or protection to the fetus. However, this action is necessary to expedite the delivery and prevent further complications, and should be done after the first intervention.
Correct Answer is A
Explanation
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.