A nurse is caring for a client who is 34 weeks pregnant.
The nurse is reviewing the client’s electronic medical record to develop a care plan.
The nurse should take which of the following actions to address the condition the client is most likely experiencing, and monitor which parameters to assess the client’s progress.
Implement seizure precautions.
Check deep tendon reflexes every hour.
Administer prescribed methyldopa.
Monitor neurologic status.
The Correct Answer is A
Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.
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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.
Correct Answer is C
Explanation
Step 1: The order is to administer Morphine 5mg IV once immediately. The available concentration is 2.5 mg/mL. To find out how many mL of morphine the nurse should prepare for administration, we need to divide the ordered dose by the available concentration.
Step 2: Calculation: 5 mg ÷ 2.5 mg/mL = 2 mL So, the nurse should prepare 2 mL of morphine for administration.
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