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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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
While Type 1 diabetes is a significant health concern, it is not the most prevalent form of diabetes. Type 2 diabetes is more common, affecting a larger proportion of the population.
Choice B rationale
Type 2 diabetes often remains undiagnosed because its symptoms can be subtle and develop slowly. People with Type 2 diabetes may not recognize these symptoms as signs of high blood sugar, leading to a delay in diagnosis and treatment.
Choice C rationale
Type 1 diabetes cannot transition to Type 2 diabetes. These are distinct conditions with different underlying causes. Type 1 diabetes is an autoimmune condition, while Type 2 diabetes is primarily associated with lifestyle factors and genetic predisposition.
Choice D rationale
Gestational diabetes mellitus (GDM) does not imply that the woman will require insulin treatment until 6 weeks postpartum. While some women with GDM may require insulin during pregnancy, this is not always the case. Furthermore, GDM usually resolves after delivery.
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