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
This is incorrect because repaglinide is not recommended for the treatment of gestational diabetes mellitus. Repaglinide is an oral antidiabetic agent that stimulates the release of insulin from the pancreas. However, it has not been adequately studied in pregnant women and may cause hypoglycemia or fetal harm.
Choice B rationale
This is correct because insulin is the preferred medication for the treatment of gestational diabetes mellitus. Insulin is a hormone that lowers the blood glucose levels by facilitating its uptake by the cells. Insulin does not cross the placenta and does not affect the fetal development. Insulin can be administered by injection or infusion, depending on the type and severity of the diabetes.
Choice C rationale
This is incorrect because glipizide is not recommended for the treatment of gestational diabetes mellitus. Glipizide is an oral antidiabetic agent that stimulates the release of insulin from the pancreas. However, it may cross the placenta and cause hypoglycemia or fetal abnormalities.
Choice D rationale
This is incorrect because acarbose is not recommended for the treatment of gestational diabetes mellitus. Acarbose is an oral antidiabetic agent that inhibits the digestion and absorption of carbohydrates in the intestine. However, it may cause gastrointestinal side effects, such as bloating, diarrhea, or flatulence, and it has not been proven to be safe or effective in pregnant women.
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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