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

Answer and Explanation

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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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale
Age of the client is not a significant risk factor for postpartum hemorrhage. While age can influence overall health and pregnancy complications, it is not directly linked to an increased risk of postpartum hemorrhage. Therefore, the age of the client, in this case, does not increase the risk for postpartum hemorrhage.
Choice B rationale
The use of forceps during delivery can increase the risk of postpartum hemorrhage. Forceps delivery is an assisted delivery method which can cause trauma to the birth canal, leading to increased bleeding after delivery. In this case, the client had a forceps-assisted delivery, which could increase her risk for postpartum hemorrhage.
Choice C rationale
A 4th degree laceration is a severe tear that occurs during delivery, extending to the anal sphincter and rectal mucosa. This type of laceration can lead to significant blood loss and increase the risk of postpartum hemorrhage. In this case, the client had a 4th degree laceration, which increases her risk for postpartum hemorrhage.
Choice D rationale
A long labor duration can increase the risk of postpartum hemorrhage. Prolonged labor can lead to uterine atony, a condition where the uterus does not contract properly after delivery, leading to increased bleeding. In this case, the client was in labor for 25 hours, which could increase her risk for postpartum hemorrhage.

A. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes C. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions

Correct Answer is A

Explanation

Choice A rationale
This is correct because a client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache is the most urgent finding. These are signs of severe preeclampsia, which can progress to eclampsia, a life-threatening condition that involves seizures, coma, and organ damage. The nurse should report this finding to the provider immediately and prepare for the delivery of the fetus and the administration of magnesium sulfate to prevent seizures.

Choice B rationale
This is incorrect because a client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes is not the most urgent finding. These are signs of mild preeclampsia, which can be managed with close monitoring, bed rest, and antihypertensive medications. The nurse should report this finding to the provider, but it is not an emergency.

Choice C rationale
This is incorrect because a client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors is not the most urgent finding. These are side effects of terbutaline, a medication that is used to stop preterm labor by relaxing the uterine muscles. The nurse should assess the client's vital signs, blood glucose, and fetal heart rate, and report any abnormal findings to the provider. The nurse should also reassure the client that the tremors are temporary and will subside when the medication is discontinued.

Choice D rationale
This is incorrect because a tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is not the most urgent finding. These are signs of preterm labor, which can be treated with tocolytic medications, such as terbutaline, to delay the delivery until the fetus is more mature. The nurse should assess the client's cervical dilation, fetal heart rate, and amniotic fluid, and report any abnormal findings to the provider. The nurse should also provide emotional support and education to the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

Correct Answer is A

Explanation

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, movable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?