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A nurse is caring for a client who is at 34 weeks of gestation.

The client reports headache, dizziness, and blurred vision for 1 week.

The nurse notes 3+ edema in lower extremities and deep tendon reflexes (DTRs) 3+ with positive clonus.

The fetal heart rate (FHR) is 140 with minimal variability.

The nurse is reviewing the client’s electronic medical record to develop a plan of care.

Which condition is the client most likely experiencing, what are two actions the nurse should take to

A.

Preeclampsia

B.

Chronic hypertension

C.

Neurologic status

D.

Liver function studies

Answer and Explanation

The Correct Answer is A

Choice A rationale 
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. 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 
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation. 
Choice C rationale 
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia. 
Choice D rationale 
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia. 
 
 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.

Correct Answer is A

Explanation

Choice A rationale
Methylergonovine is a medication that is primarily used to prevent or treat excessive bleeding after childbirth. It works by increasing the rate and strength of contractions and the stiffness of the uterus muscles, which helps to decrease bleeding. This medication is given in a hospital or clinic setting. Therefore, the nurse should inform the client that this medication is intended to prevent postpartum hemorrhage.
Choice B rationale
While preventing postpartum infection is important, methylergonovine is not specifically used for this purpose. Postpartum infection is typically prevented and treated with antibiotics and good hygiene practices.
Choice C rationale
Thromboembolic events, such as blood clots, can be a risk after childbirth. However, methylergonovine is not used to prevent these events. Anticoagulant medications are typically used to prevent thromboembolic events.
Choice D rationale
Methylergonovine is not used to prevent hypertension. In fact, it can cause increased blood pressure as a side effect. Therefore, it would not be used as a preventative measure for hypertension.

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