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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.

A.

Implement seizure precautions.

B.

Check deep tendon reflexes every hour.

C.

Administer prescribed methyldopa.

D.

Monitor neurologic status.

Answer and Explanation

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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Related Questions

Correct Answer is A

Explanation

Choice A rationale
The maternal serum alpha-fetoprotein (MSAFP) test is a screening test that measures the level of alpha-fetoprotein in the mother’s blood during pregnancy. It is used to assess the likelihood of certain birth defects, including neural tube defects such as spina bifida.
Choice B rationale
The MSAFP test does not assess fetal lung maturity. Other tests, such as amniocentesis, can be used to assess this.
Choice C rationale
The MSAFP test does not identify Rh incompatibility between the mother and fetus. Rh incompatibility is typically determined through blood typing and antibody screening.
Choice D rationale
While the MSAFP test can provide valuable information about the health of the fetus, it does not assess various markers of fetal well-being. It is specifically used to screen for certain birth defects.

Correct Answer is C

Explanation

Choice A reason:

Fetal head compression is associated with early decelerations, not late. Early decelerations are a normal finding during labor as the fetal head is compressed during contractions, leading to a vagal response that temporarily decreases the heart rate.

Choice B reason:

Umbilical cord compression leads to variable decelerations, not late. Variable decelerations can occur at any time during the contraction cycle and are caused by compression of the umbilical cord, which can restrict blood flow to the fetus.

The correct answer is C. Uteroplacental insufficiency.

Late decelerations are indicative of uteroplacental insufficiency, which is a condition where the placenta is not delivering enough oxygen and nutrients to the fetus.

Choice D reason:

Maternal bradycardia, which is a slower than normal heart rate in the mother, does not cause late decelerations in the fetus. Instead, maternal bradycardia can be a separate concern and does not directly affect the fetal heart rate pattern observed on the monitor.

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