A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.

Apply internal fetal monitor.

Prepare client for dilation and curettage with suction

Administer 1 hr glucose tolerance test

Refer client to perinatal loss support group

Provide the client with instructions on medroxyprogesterone therapy.

Administer Rho (D) immune globulin

Answer and Explanation

Correct Answer : B,D,F

A. Apply internal fetal monitor: An internal fetal monitor is used to assess fetal heart rate and contractions in a viable pregnancy. In this case, the client has a molar pregnancy with no viable fetus, so fetal monitoring is not appropriate and provides no clinical benefit.

B. Prepare client for dilation and curettage with suction: Suction dilation and curettage (D&C) is the primary treatment for a molar pregnancy to remove abnormal trophoblastic tissue. Planning for this procedure is essential to prevent complications such as hemorrhage, persistent gestational trophoblastic disease, and infection.

C. Administer 1 hr glucose tolerance test: Glucose screening is not indicated at this time. The client is only 20 weeks gestation and is being managed for a molar pregnancy, not for routine prenatal care or gestational diabetes screening. This test is not a priority.

D. Refer client to perinatal loss support group: A molar pregnancy is considered a pregnancy loss, and the client may experience emotional distress. Referral to a perinatal loss support group provides psychological support and helps the client cope with grief and anxiety associated with this event.

E. Provide the client with instructions on medroxyprogesterone therapy: Medroxyprogesterone therapy is not indicated for managing a molar pregnancy. Contraception may be discussed after treatment, but this is not an immediate priority during acute management of the condition.

F. Administer Rho(D) immune globulin: The client is Rh-negative, and any procedure that may cause fetomaternal hemorrhage, such as D&C, requires administration of Rho(D) immune globulin to prevent isoimmunization in future pregnancies. This is a critical prophylactic intervention in Rh-negative clients.

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Correct Answer is C

Explanation

A. Assist the client to a supine position: There is no requirement to maintain a supine position for bacterial meningitis. Clients are often more comfortable with the head of the bed elevated to reduce intracranial pressure and promote comfort. Supine positioning alone does not prevent disease transmission or improve outcomes.

B. Recommend prophylactic acyclovir for the client's family: Acyclovir is an antiviral medication and is not effective against bacterial infections. Family members may require prophylactic antibiotics if exposed, but antiviral therapy is inappropriate for bacterial meningitis.

C. Initiate droplet precautions for the client: Bacterial meningitis, particularly Neisseria meningitidis, can be transmitted via respiratory droplets. Implementing droplet precautions, including the use of masks and limiting close contact, protects healthcare staff and other clients from infection. This is a standard and critical infection control measure.

D. Perform a Glasgow Coma Scale every 24 hr: Clients with bacterial meningitis are at risk for rapid neurological changes. Performing a Glasgow Coma Scale only once every 24 hours is insufficient. Neurological status should be monitored more frequently to promptly identify deterioration.

A. Brush teeth immediately after eating B. Lay down for 30 min after meals. C. Drink 12 oz of water with each meal. D. Eat a dry carbohydrate before getting out of bed.

Correct Answer is D

Explanation

A. Brush teeth immediately after eating: Brushing teeth right after eating may worsen nausea and vomiting due to stimulation of the gag reflex or irritation of the oral mucosa. It is better to rinse the mouth with water or a mild mouthwash instead.

B. Lay down for 30 min after meals: Lying down after eating can exacerbate nausea and increase the risk of reflux. Remaining upright after meals promotes gastric emptying and reduces symptoms of morning sickness.

C. Drink 12 oz of water with each meal: Drinking large amounts of fluid during meals can distend the stomach and worsen nausea. Small, frequent sips of fluids between meals are more effective in maintaining hydration without increasing discomfort.

D. Eat a dry carbohydrate before getting out of bed: Consuming a dry carbohydrate, such as toast or crackers, before rising in the morning helps stabilize blood sugar levels and reduce nausea associated with morning sickness. This is a safe and effective strategy for managing early pregnancy nausea.

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A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.