A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.
Which of the following actions should the nurse plan to take?

Ensure that the side rails are up on the client's bed.

Ambulate the client every 4 hr.

Check the fetal heart rate twice daily.

Provide the client with a low-protein diet.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.

Choice B rationale:

Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.

Choice C rationale:

Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.

Choice D rationale:

Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.

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Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

A. Keep the client's television on with the volume low B. Insert an indwelling urinary catheter to minimize interaction with the client C. Consult the provider regarding administering a mild sedative on a schedule D. Move the client to a room near the nurses' station

Correct Answer is D

Explanation

Move the client to a room near the nurses' station.

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.Which of the following actions should the nurse plan to take?

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A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia.
Which of the following actions should the nurse plan to take?