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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Examination to determine cervical status is not an appropriate nursing action for a client who has suspected placenta previa. This may cause trauma to the placenta and increase the bleeding. The nurse should avoid any vaginal examinations or interventions unless absolutely necessary.
Choice B rationale
Magnesium sulfate infusion is not an appropriate nursing action for a client who has suspected placenta previa. This medication is used to prevent or treat seizures in clients who have preeclampsia or eclampsia, not placenta previa. It may also cause adverse effects such as respiratory depression, hypotension, and decreased fetal heart rate.
Choice C rationale
Initiation of pushing is not an appropriate nursing action for a client who has suspected placenta previa. This may worsen the bleeding and compromise the fetal oxygenation. The nurse should instruct the client to avoid any bearing down or straining.
Choice D rationale
Preparation for cesarean birth is an appropriate nursing action for a client who has suspected placenta previa. This is the preferred mode of delivery for clients who have placenta previa, especially if the bleeding is severe or the fetal distress is present. The nurse should monitor the client's vital signs, fetal heart rate, and blood loss, and notify the provider immediately.
Correct Answer is D
Explanation
Choice A rationale
Abdominal pain with scant red vaginal bleeding is not a finding that supports placenta previa. This finding may indicate placental abruption, which is the premature separation of the placenta from the uterine wall. Placental abruption is a medical emergency that can cause severe bleeding, pain, and fetal distress.
Choice B rationale
Intermittent abdominal pain following passage of bloody mucus is not a finding that supports placenta previa. This finding may indicate the onset of labor, which is characterized by contractions and the expulsion of the mucus plug that seals the cervix. Labor can be normal or preterm, depending on the gestational age of the fetus.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a finding that supports placenta previa. This finding may indicate uterine rupture, which is the tearing of the uterine wall. Uterine rupture is a rare but life-threatening complication that can cause severe bleeding, shock, and fetal death.
Choice D rationale
Painless red vaginal bleeding is a finding that supports placenta previa. Placenta previa is a condition where the placenta covers part or all of the cervix, which is the opening of the uterus. Placenta previa can cause bleeding when the cervix dilates or contracts, or when the placenta detaches from the uterine wall. The bleeding is usually painless because the placenta has no nerve endings.
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