A nurse is providing care for a patient who is at 34 weeks of gestation. The nurse is reviewing the patient’s electronic medical record to develop a plan of care. Which condition is the patient most likely experiencing, what are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?
Preeclampsia, initiate seizure precautions, monitor neurological status and liver function studies.
Hypertension, prepare for bed rest, monitor blood pressure and heart rate.
Gestational diabetes, administer insulin, monitor blood glucose levels and fetal heart rate.
Preterm labor, administer tocolytics, monitor contraction pattern and cervical dilation.
The Correct Answer is A
Choice A rationale
Preeclampsia is a condition that can occur during pregnancy, characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. If a patient is experiencing preeclampsia, the nurse should initiate seizure precautions, as seizures can occur in severe cases. The nurse should also monitor the patient’s neurological status and liver function studies, as these can be affected by preeclampsia.
Choice B rationale
Hypertension, or high blood pressure, can occur during pregnancy, but the actions listed do not fully address the condition. While bed rest was once commonly recommended for high blood pressure during pregnancy, research has not shown it to be effective. Monitoring blood pressure and heart rate is important, but other interventions, such as medication, may also be necessary.
Choice C rationale
Gestational diabetes is a condition characterized by high blood sugar that develops during pregnancy. Insulin may be administered to help control blood glucose levels. The nurse should monitor blood glucose levels and fetal heart rate, as gestational diabetes can affect both the mother and the baby. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.
Choice D rationale
Preterm labor refers to labor that begins before the 37th week of pregnancy. Tocolytics may be administered to slow or stop contractions. The nurse should monitor the contraction pattern and cervical dilation to assess for progression of labor. However, the condition the patient is most likely experiencing, given the gestational age and symptoms, is preeclampsia.
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Correct Answer is D
Explanation
Choice A rationale
Increased deposits of fat in the chest and shoulder area are not typically associated with respiratory distress syndrome in a newborn. Macrosomic newborns, or those with a high birth weight, may have increased fat deposits, but this is not the primary cause of respiratory distress.
Choice B rationale
A brachial plexus injury is a type of birth injury that can occur due to difficulties during delivery, such as a prolonged labor or a breech presentation. It involves damage to the bundle of nerves that supply the arms and hands. However, it does not directly cause respiratory distress syndrome.
Choice C rationale
Increased blood viscosity could potentially contribute to respiratory distress, but it is not the most likely cause in a macrosomic newborn whose mother has poorly controlled type 2 diabetes. High blood sugar levels in the mother can lead to high insulin levels in the newborn, which is a more direct cause of respiratory distress.
Choice D rationale
Hyperinsulinemia, or high levels of insulin in the blood, is the most likely cause of respiratory distress in this case. When a mother has poorly controlled diabetes, the baby’s pancreas may respond to high glucose levels by producing extra insulin. After birth, the baby may have hypoglycemia (low blood sugar) and increased red blood cell production, both of which can contribute to respiratory distress.
Correct Answer is ["D"]
Explanation
A blood pressure of 179/99 mm Hg in a pregnant client is a cause for concern and should be reported to the provider. This could be a sign of preeclampsia, a serious condition that can occur during pregnancy characterized by high blood pressure and damage to other organ systems, most often the liver and kidneys. The other vital signs (temperature, pulse rate, and respiratory rate) are within normal ranges for a pregnant woman.
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