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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypocalcemia is not the priority focus of care, as it is a low level of calcium in the blood that can cause muscle twitching, seizures, or cardiac arrhythmias. Hypocalcemia can affect newborns who have mothers with diabetes mellitus, but it is less common and less severe than hypoglycemia.
Choice B reason: Hyperbilirubinemia is not the priority focus of care, as it is a high level of bilirubin in the blood that can cause jaundice, a yellowish discoloration of the skin and eyes. Hyperbilirubinemia can affect newborns who have macrosomia, but it is usually a benign and self-limiting condition that resolves within a few days.
Choice C reason: Hypomagnesemia is not the priority focus of care, as it is a low level of magnesium in the blood that can cause tremors, tetany, or seizures. Hypomagnesemia can affect newborns who have mothers with diabetes mellitus, but it is rare and usually asymptomatic.
Choice D reason: Hypoglycemia is the priority focus of care, as it is a low level of glucose in the blood that can cause diaphoresis, jitteriness, lethargy, or apnea. Hypoglycemia can affect newborns who have macrosomia and mothers with diabetes mellitus, as they have increased insulin production and decreased glucose supply after birth. Hypoglycemia can lead to brain damage or death if not treated promptly.
Correct Answer is B
Explanation
Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.
Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.
Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.
Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.
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