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 A
Explanation
Choice A rationale
As labor begins, the cervix starts to soften, shorten and thin (efface). This process is often expressed in percentages¹. This is a sign of true labor².
Choice B rationale
The station of the presenting part refers to the position of the baby's head in relation to the mother's pelvis. While it can indicate progress in labor, it is not a definitive sign of true labor.
Choice C rationale
Rupture of the membranes, or water breaking, can occur before or during labor. However, it is not a reliable sign of true labor as it can also occur in preterm labor or even without contractions.
Choice D rationale
The pattern of contractions can be a sign of labor. True labor contractions are regular, increase in intensity, and do not ease up with change in activity or position². However, contractions alone are not a definitive sign of true labor as they can also occur in false labor (Braxton Hicks contractions).
Correct Answer is A
Explanation
Choice A rationale
Hypoglycemia is a low blood glucose level that can occur in newborns who have macrosomia and whose mothers have diabetes mellitus. This is because the fetus produces excess insulin in response to the high maternal glucose levels, and after birth, the insulin level remains high while the glucose level drops. Hypoglycemia can cause seizures, lethargy, poor feeding, and brain damage in the newborn.
Choice B rationale
Hypomagnesemia is a low magnesium level that can occur in newborns who have intrauterine growth restriction (IUGR) and whose mothers have preeclampsia. This is because the placental insufficiency and the maternal hypertension impair the magnesium transfer to the fetus. Hypomagnesemia can cause tremors, irritability, hypotonia, and cardiac arrhythmias in the newborn.
Choice C rationale
Hyperbilirubinemia is a high bilirubin level that can occur in newborns who have hemolytic disease of the newborn (HDN) and whose mothers have Rh incompatibility or ABO incompatibility. This is because the maternal antibodies destroy the fetal red blood cells, which release bilirubin. Hyperbilirubinemia can cause jaundice, kernicterus, and brain damage in the newborn.
Choice D rationale
Hypocalcemia is a low calcium level that can occur in newborns who are preterm, small for gestational age (SGA), or have perinatal asphyxia. This is because the immature parathyroid gland, the low body fat, or the hypoxia impair the calcium regulation in the newborn. Hypocalcemia can cause jitteriness, tetany, seizures, and cardiac arrhythmias in the newborn.
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