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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Increased subcutaneous fat is not a typical finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have less subcutaneous fat, and may appear thin and wasted.

Choice B reason: Dry, cracked skin is a common finding in a newborn who was born at 42.5 weeks of gestation, because the skin has been exposed to the amniotic fluid for a prolonged period. The skin may also appear peeling, wrinkled, or leathery.

Choice C reason: Scant scalp hair is not a usual finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a preterm newborn. A postterm newborn tends to have more scalp hair, and may also have long nails and abundant lanugo.

Choice D reason: Copious vernix is not a specific finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have little or no vernix, which is a white, cheesy substance that protects the skin in utero.

A. Primigravida in spontaneous labor with preterm twins B. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor D. Woman with severe preeclampsia on magnesium sulfate whose labor is being induced

Correct Answer is C

Explanation

Choice A reason: Primigravida in spontaneous labor with preterm twins is not at the greatest risk for early postpartum hemorrhage, as preterm births are associated with lower blood loss and smaller placentas. However, this client may have other complications, such as preterm labor, premature rupture of membranes, or fetal growth restriction.

Choice B reason: Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress is not at the greatest risk for early postpartum hemorrhage, as cesarean births are associated with higher blood loss and larger incisions. However, this client may have other complications, such as infection, wound dehiscence, or thromboembolism.

Choice C reason: Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor is at the greatest risk for early postpartum hemorrhage, as multiparity and rapid labor are both risk factors for uterine atony, which is the most common cause of early postpartum hemorrhage. Uterine atony is a condition where the uterus fails to contract and retract after delivery, and can cause excessive bleeding and hypovolemic shock.

Choice D reason: Woman with severe preeclampsia on magnesium sulfate whose labor is being induced is not at the greatest risk for early postpartum hemorrhage, as preeclampsia and magnesium sulfate are both risk factors for late postpartum hemorrhage, which occurs after 24 hours of delivery. However, this client may have other complications, such as eclampsia, HELLP syndrome, or placental abruption.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Which client is at greatest risk for early postpartum hemorrhage (PPH)?

Correct Answer is C

Explanation

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