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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

  • G (Gravida): Total number of pregnancies → 4

  • T (Term births): Delivered at 37 weeks or more → One (39 weeks) → T = 1

  • P (Preterm births): Delivered between 20–36 weeks → Twins (34 weeks, 1 pregnancy) + One at 35 weeks = 2 preterm pregnancies → P = 2

  • A (Abortions): Pregnancies ending before 20 weeks → 0

  • L (Living children): One from term birth, two from twins, and one from the other preterm = 4 living children → L = 4

Correct Answer: D. G4 T1 P2 A0 L4

Correct Answer is A

Explanation

Choice A rationale

The client’s symptoms of elevated blood pressure, 3+ edema in the lower extremities, and 3+ proteinuria are indicative of preeclampsia. Preeclampsia is a complication of pregnancy that begins after 20 weeks of gestation in women whose blood pressure had previously been in the standard range. It is associated with high blood pressure and signs of damage to another organ system, often the liver and kidneys. In this case, the nurse should initiate seizure precautions and monitor the client’s neurological status and liver function studies. Seizure precautions are necessary because eclampsia, a severe form of preeclampsia, can lead to seizures. Monitoring neurological status can help detect changes in the client’s condition, and liver function studies can help assess the impact of preeclampsia on the liver.

Choice B rationale

While the client does have a history of chronic hypertension, the current symptoms suggest a condition more severe than chronic hypertension. Administering antihypertensive medication and monitoring blood pressure and heart rate would be appropriate actions for managing chronic hypertension, but they may not be sufficient to address the client’s current condition.

Choice C rationale

Gestational diabetes is a condition characterized by high blood sugar levels that develop during pregnancy in women who did not have diabetes before pregnancy. The client’s symptoms do not indicate gestational diabetes. While administering insulin and monitoring blood glucose levels and fetal heart rate would be appropriate actions for managing gestational diabetes, they do not address the client’s current symptoms.

Choice D rationale

Preterm labor refers to regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. The client’s symptoms do not suggest preterm labor. Administering tocolytics and monitoring contraction pattern and cervical dilation would be appropriate actions for managing preterm labor, but they do not address the client’s current symptoms.

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