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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 D

Explanation

Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.

Correct Answer is ["C","D","E"]

Explanation

The correct answers are Choices C, D, and E.
Choice A rationale
Fetal neck translucency is not typically evaluated during a biophysical profile. It is usually assessed during a first trimester ultrasound to screen for chromosomal abnormalities.
Choice B rationale
Fetal gender is not typically evaluated during a biophysical profile. The focus of a biophysical profile is on assessing the health and well-being of the fetus.
Choice C rationale
Fetal motion is one of the aspects evaluated during a biophysical profile. It is assessed to determine the activity level of the fetus.
Choice D rationale
Fetal breathing is one of the aspects evaluated during a biophysical profile. It is assessed to determine the respiratory function of the fetus.
Choice E rationale
Amniotic fluid volume is one of the aspects evaluated during a biophysical profile. It is assessed to determine the amount of amniotic fluid surrounding the fetus.

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