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A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?

A.

Assess deep tendon reflexes every hour

B.

Continuous fetal monitoring

C.

Ambulate twice daily

D.

Obtain a daily weight

Answer and Explanation

The Correct Answer is C

Choice A rationale 
Assessing deep tendon reflexes every hour is a common practice in managing severe preeclampsia. Hyperreflexia can be a sign of worsening pre-eclampsia. 
Choice B rationale 
Continuous fetal monitoring is typically recommended for patients with severe pre-eclampsia. This allows for early detection of fetal distress. 
Choice C rationale 
Ambulating twice daily may not be appropriate for a patient with severe pre-eclampsia at 35 weeks of gestation. Bed rest is often recommended to help lower blood pressure and reduce the risk of complications. 
Choice D rationale 
Obtaining a daily weight is a common practice in managing severe pre-eclampsia. Sudden weight gain can be a sign of worsening pre-eclampsia. 
 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. While preparing the abdominal and perineal areas may be necessary in preparation for delivery, it is not the immediate priority.
Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. IV access allows for rapid administration of fluids and medications, which may be necessary to stabilize the client’s condition.
Choice C rationale
Inserting an indwelling urinary catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While a urinary catheter may be necessary in preparation for delivery or surgery, it is not the immediate priority.
Choice D rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While obtaining informed consent may be necessary before performing certain procedures or surgeries, it is not the immediate priority.

Correct Answer is A

Explanation

The priority finding for a nurse caring for a client receiving opioid epidural analgesia during labor would be a blood pressure of 80/56 mm Hg. This could indicate hypotension, a known side effect of epidural analgesia. Hypotension can lead to decreased perfusion to vital organs, including the placenta, potentially compromising the fetus. Immediate interventions might include positioning the patient on her side, increasing the rate of IV fluids, and notifying the healthcare provider.

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