A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client's vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The nurse is reviewing the client's medical record to develop a plan of care.
What are the two most important nursing interventions for this client?
Monitor the fetal heart rate and movement
Administer magnesium sulfate as prescribed
Encourage the client to drink plenty of fluids
Educate the client about the signs of preterm labor
The Correct Answer is A
Choice A rationale
Monitoring the fetal heart rate and movement is an important nursing intervention for this client. The client is at risk of fetal distress due to the high blood pressure, the preeclampsia, and the gestational diabetes. The fetal heart rate and movement can indicate the fetal well-being and oxygenation. The nurse should monitor the fetal heart rate continuously and perform a nonstress test or a biophysical profile as indicated.
Choice B rationale
Administering magnesium sulfate as prescribed is an important nursing intervention for this client. The client is at risk of seizures due to the severe preeclampsia. Magnesium sulfate is a medication that prevents and treats seizures in preeclamptic clients. The nurse should administer magnesium sulfate as prescribed and monitor the client's vital signs, reflexes, urine output, and magnesium level.
Choice C rationale
Encouraging the client to drink plenty of fluids is not an important nursing intervention for this client. The client is at risk of fluid overload due to the high blood pressure and the preeclampsia. Fluid overload can cause pulmonary edema, heart failure, and cerebral edema in the client. The nurse should restrict the client's fluid intake and monitor the client's weight, edema, and lung sounds.
Choice D rationale
Educating the client about the signs of preterm labor is not an important nursing intervention for this client. The client is at 34 weeks of gestation, which is close to the term pregnancy. The client is more likely to have a planned delivery or an induction of labor due to the high-risk conditions. The nurse should educate the client about the signs of preeclampsia, such as headache, blurred vision, epigastric pain, and decreased urine output.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This is incorrect because 3 cm above the umbilicus is not the expected location for the fundus at 22 weeks of gestation. The fundus is the upper part of the uterus that can be felt by abdominal palpation. The fundal height is measured from the symphysis pubis to the top of the fundus. The fundal height usually corresponds to the gestational age in weeks, plus or minus 2 cm. Therefore, at 22 weeks of gestation, the fundal height should be around 22 cm, which is slightly above the umbilicus.
Choice B rationale
This is incorrect because 3 cm below the umbilicus is not the expected location for the fundus at 22 weeks of gestation. The fundus is the upper part of the uterus that can be felt by abdominal palpation. The fundal height is measured from the symphysis pubis to the top of the fundus. The fundal height usually corresponds to the gestational age in weeks, plus or minus 2 cm. Therefore, at 22 weeks of gestation, the fundal height should be around 22 cm, which is slightly above the umbilicus.
Choice C rationale
This is incorrect because slightly below the umbilicus is not the expected location for the fundus at 22 weeks of gestation. The fundus is the upper part of the uterus that can be felt by abdominal palpation. The fundal height is measured from the symphysis pubis to the top of the fundus. The fundal height usually corresponds to the gestational age in weeks, plus or minus 2 cm. Therefore, at 22 weeks of gestation, the fundal height should be around 22 cm, which is slightly above the umbilicus.
Choice D rationale
This is correct because slightly above the umbilicus is the expected location for the fundus at 22 weeks of gestation. The fundus is the upper part of the uterus that can be felt by abdominal palpation. The fundal height is measured from the symphysis pubis to the top of the fundus. The fundal height usually corresponds to the gestational age in weeks, plus or minus 2 cm. Therefore, at 22 weeks of gestation, the fundal height should be around 22 cm, which is slightly above the umbilicus.
Correct Answer is A
Explanation
Choice A rationale
This is correct because blood pressure 80/56 mm Hg is the nurse's priority finding. It indicates hypotension, which is a common and serious complication of epidural analgesia. Hypotension can compromise the maternal and fetal perfusion and oxygenation, leading to fetal distress and acidosis. The nurse should immediately administer oxygen, fluids, and vasopressors as prescribed, and monitor the fetal heart rate and variability.
Choice B rationale
This is incorrect because temperature 38.2°C (100.8°F) is not the nurse's priority finding. It indicates a fever, which could be a sign of infection or dehydration. The nurse should assess the client for other signs of infection, such as chills, malaise, or foul-smelling discharge, and administer antipyretics and antibiotics as prescribed. The nurse should also ensure adequate hydration and cooling measures for the client.
Choice C rationale
This is incorrect because the client reports weakness of the lower extremities is not the nurse's priority finding. It indicates a side effect of epidural analgesia, which blocks the nerve impulses from the lower spinal segments. The nurse should assess the client's motor and sensory function, and adjust the epidural infusion rate as prescribed. The nurse should also assist the client with positioning and mobility, and prevent pressure ulcers and nerve injuries.
Choice D rationale
This is incorrect because the client reports profuse itching is not the nurse's priority finding. It indicates a side effect of opioid epidural analgesia, which stimulates the histamine receptors in the skin. The nurse should assess the client's skin condition, and administer antihistamines as prescribed. The nurse should also provide comfort measures, such as cool compresses, lotion, or massage, for the client.
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