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 B
Explanation
Choice A rationale
Vaginal discharge is not a finding that indicates preeclampsia. Vaginal discharge is a normal occurrence during pregnancy, as the cervix and vaginal walls soften and produce more mucus. Vaginal discharge can also indicate infections, such as yeast or bacterial vaginosis, which are not related to preeclampsia.
Choice B rationale
Elevated blood pressure is a finding that indicates preeclampsia. Preeclampsia is a condition that causes high blood pressure and proteinuria in pregnant women after 20 weeks of gestation. Preeclampsia can lead to serious complications, such as eclampsia, HELLP syndrome, and placental abruption, which can endanger the mother and the fetus. The nurse should monitor the client's blood pressure and report any readings above 140/90 mm Hg.
Choice C rationale
Joint pain is not a finding that indicates preeclampsia. Joint pain is a common complaint during pregnancy, as the hormones and weight gain cause changes in the joints and ligaments. Joint pain can also indicate other conditions, such as arthritis, gout, or lupus, which are not related to preeclampsia.
Choice D rationale
Increased urine output is not a finding that indicates preeclampsia. Increased urine output is a normal occurrence during pregnancy, as the growing uterus puts pressure on the bladder and the kidneys filter more blood. Increased urine output can also indicate diabetes, urinary tract infection, or diuretic use, which are not related to preeclampsia.
Correct Answer is B
Explanation
Choice A rationale
Preparing the abdominal and perineal areas is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may indicate placenta previa, a condition where the placenta covers the cervical opening, which can cause life-threatening hemorrhage for both the mother and the fetus. The priority is to stabilize the client's hemodynamic status and prevent hypovolemic shock.
Choice B rationale
Initiating IV access is the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This allows the nurse to administer fluids and blood products as needed to maintain the client's blood pressure and perfusion. It also provides a route for administering medications such as tocolytics, which can inhibit uterine contractions and reduce bleeding.
Choice C rationale
Inserting a Foley catheter is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may increase the risk of infection and trauma to the lower urinary tract. It is also contraindicated in placenta previa, as it may dislodge the placenta and worsen the bleeding.
Choice D rationale
Administering oxygen via face mask is not the priority nursing action for a client who has a large amount of painless, bright red vaginal bleeding. This may be beneficial to improve the oxygenation of the mother and the fetus, but it does not address the underlying cause of the bleeding or the potential hypovolemia. Oxygen therapy should be initiated after securing IV access and fluid resuscitation.
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