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 C
Explanation
Choice A rationale
Changing the client's position is not the first action the nurse should take. Changing the client's position may improve the blood flow and oxygen delivery to the placenta and the fetus, but it is not the most urgent intervention. The nurse should change the client's position after administering oxygen and notifying the provider.
Choice B rationale
Applying a fetal scalp electrode is not the first action the nurse should take. Applying a fetal scalp electrode may provide a more accurate and continuous monitoring of the FHR, but it is not the most urgent intervention. The nurse should apply a fetal scalp electrode only if the external monitor is not reliable or if the provider orders it.
Choice C rationale
Administering oxygen at 10 L/min via a nonrebreather mask is the first action the nurse should take. Administering oxygen is the most urgent intervention to increase the oxygen saturation and prevent fetal hypoxia. Late decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen to the fetus. The nurse should administer oxygen and notify the provider immediately.
Choice D rationale
Increasing the rate of the IV infusion is not the first action the nurse should take. Increasing the rate of the IV infusion may improve the blood volume and perfusion to the placenta and the fetus, but it is not the most urgent intervention. The nurse should increase the rate of the IV infusion after administering oxygen and notifying the provider.
Correct Answer is D
Explanation
Choice A rationale
This is incorrect because the right upper quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the same side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice B rationale
This is incorrect because the left upper quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the opposite side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice C rationale
This is incorrect because the left lower quadrant is not the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the opposite side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
Choice D rationale
This is correct because the right lower quadrant is the most likely location for fetal heart tones. The round, firm, movable part in the fundus of the uterus indicates that the fetal head is in the breech position. The long, smooth surface on the client's right side suggests that the fetal spine is on the same side. Therefore, the fetal heart tones would be best heard in the lower right quadrant, where the fetal chest is located.
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