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 C
Explanation
Choice A rationale
Implementing seizure precautions is not necessary based on these lab results. Seizure precautions are typically implemented for patients with a known seizure disorder or those who are at risk for seizures, such as patients with severe preeclampsia or eclampsia, neither of which can be diagnosed based on these lab results.
Choice B rationale
Checking deep tendon reflexes every hour is not indicated based on these lab results. This action is typically taken for patients with altered neurological status or those receiving certain medications that can affect muscle tone.
Choice C rationale
Reviewing the daily logs of the patient is a good practice in general to monitor the patient’s progress and response to treatment. However, it is not a specific action that should be taken based on these lab results.
Choice D rationale
Obtaining a prescription for methyldopa is not indicated based on these lab results.
Methyldopa is a medication used to treat high blood pressure, and there is no indication from these lab results that the patient has high blood pressure.
Correct Answer is B
Explanation
Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. While preparing the abdominal and perineal areas may be necessary in preparation for delivery, it is not the immediate priority.
Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. This type of bleeding is suggestive of placenta previa, a condition where the placenta covers part or all of the cervix, preventing normal delivery. IV access allows for rapid administration of fluids and medications, which may be necessary to stabilize the client’s condition.
Choice C rationale
Inserting an indwelling urinary catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While a urinary catheter may be necessary in preparation for delivery or surgery, it is not the immediate priority.
Choice D rationale
Witnessing the signature for informed consent for surgery is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding at 38 weeks of gestation. While obtaining informed consent may be necessary before performing certain procedures or surgeries, it is not the immediate priority.
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