A nurse is caring for a client who is pregnant.
Complete the following sentence by using the lists of options.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should first assist with is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
The client presents with severe hypertension, proteinuria, hyperreflexia, and elevated liver enzymes, all indicating high risk for eclampsia and fetal compromise. Management priorities include preventing maternal seizures and closely monitoring fetal status due to decreased uteroplacental perfusion. Understanding ABC priorities and maternal-fetal risk stratification is essential in obstetric emergencies.
Rationale for correct choices:
• Seizure precautions are the highest priority because the client exhibits severe preeclampsia with hyperreflexia, severe hypertension, and neurological symptoms (persistent headache). These findings place the client at imminent risk for eclampsia, which can be life-threatening. Seizure precautions include padded side rails, reduced stimulation, and readily available magnesium sulfate administration.
• After initiating maternal safety measures, assessing fetal well-being is essential due to risk of uteroplacental insufficiency. Severe preeclampsia can reduce placental perfusion, leading to fetal hypoxia or distress. Continuous fetal monitoring helps detect early signs of compromise such as decelerations or reduced variability. Evaluating fetal status ensures timely intervention if deterioration occurs.
Rationale for incorrect choices:
• Betamethasone is important for fetal lung maturity in preterm pregnancies, but it is not the immediate priority in severe preeclampsia. Maternal stabilization always takes precedence over fetal lung maturity enhancement. There is an immediate risk of seizure, which is life-threatening to the mother. Therefore, seizure prevention must be initiated before corticosteroid administration.
• Although urinary catheterization is useful for strict intake and output monitoring in preeclampsia, it is not the first action. Maternal neurologic safety and seizure prevention take priority over fluid monitoring. Catheter placement is important but should follow stabilization measures. Therefore, it is not the initial intervention.
• Acetaminophen may provide symptomatic relief for headache, but it does not address the underlying pathophysiology of severe preeclampsia. Pain relief is not a priority compared to preventing seizures or assessing fetal status. Therefore, this is not the next priority action.
• A 24-hour urine collection is useful for confirming proteinuria severity, but the client already has documented 3+ proteinuria and a diagnosis consistent with severe preeclampsia. This is a diagnostic follow-up rather than an immediate priority. Initiating seizure precautions and assessing fetal status are more urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Intermittent enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube is used to provide nutrition directly into the stomach in clients who cannot safely swallow. Safe administration requires proper positioning, tube patency checks, and prevention of aspiration or clogging. Nursing care focuses on maintaining tube function and reducing complications such as aspiration pneumonia, tube obstruction, and gastric intolerance. Correct technique ensures effective and safe delivery of enteral nutrition.
Rationale:
A. Elevating the head of the bed to 20 degrees is insufficient for preventing aspiration during and after enteral feeding. The recommended position is typically 30–45 degrees to reduce the risk of gastric reflux and aspiration. A 20-degree elevation does not provide adequate protection for airway safety.
B. Withholding feeding if 50 mL of residual is present is not appropriate because this amount is generally within acceptable limits depending on facility policy. Small residual volumes are common and do not necessarily indicate intolerance. Routine practice focuses on trends in residuals and clinical signs rather than a single measurement alone.
C. Positioning the client supine for 1 hour after feeding increases the risk of aspiration. Supine positioning allows gastric contents to reflux into the esophagus and potentially enter the airway. Clients should remain upright or in a semi-Fowler’s position during and after feeding to promote safe digestion.
D. Administering 30 mL of water prior to feeding helps ensure patency of the PEG tube and reduces the risk of clogging. It also prepares the gastrointestinal tract for feeding and helps verify proper tube function. Flushing before and after feeding is a standard nursing practice to maintain tube integrity and safe nutrition delivery.
Correct Answer is C
Explanation
Iron supplementation with medications such as Ferrous sulfate is commonly prescribed for children with iron deficiency anemia to restore hemoglobin levels and replenish iron stores. Effective administration requires proper technique to maximize absorption and reduce adverse effects such as gastrointestinal irritation and tooth discoloration. Caregivers must understand how to administer the medication correctly and recognize expected side effects versus abnormal findings. Education focuses on improving absorption and ensuring safe, effective therapy.
Rationale:
A. “I’ll give my child the iron with milk.” This is incorrect because calcium in milk interferes with iron absorption in the gastrointestinal tract. Dairy products bind to iron and reduce its bioavailability, making the medication less effective. Iron should ideally be given with water or a source of vitamin C, such as orange juice, to enhance absorption.
B. “I’ll notify the provider if my child becomes nauseated.” This reflects a misunderstanding because mild gastrointestinal upset is a common and expected side effect of iron therapy. Nausea can often be minimized by giving the medication with a small amount of food, although absorption may slightly decrease. Severe or persistent symptoms may require adjustment, but mild nausea does not typically require provider notification.
C. “I’ll give my child the iron through a straw.” This is correct because liquid iron can stain teeth due to its dark color and metallic content. Using a straw helps minimize contact with teeth, reducing the risk of permanent discoloration. Additionally, rinsing the mouth or brushing teeth after administration further helps protect dental enamel.
D. “I’ll notify the provider if my child’s stools are tarry.” This is incorrect because dark, tarry stools are an expected and harmless side effect of oral iron therapy. This occurs due to unabsorbed iron passing through the gastrointestinal tract and is not an indication of bleeding in this context. Caregivers should be reassured that this is a normal response to treatment.
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