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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Abdominal pain accompanied by minimal red vaginal bleeding is not a typical symptom of placenta previa. In placenta previa, the placenta covers all or part of the cervix, which can cause severe bleeding. However, this bleeding is typically not associated with abdominal pain.
Choice B rationale
Intermittent abdominal pain following the passage of bloody mucus is not a common symptom of placenta previa. This symptom is more commonly associated with labor or other conditions, but not specifically with placenta previa.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a typical symptom of placenta previa. This could be a sign of other complications such as uterine rupture or placental abruption, which are serious conditions that require immediate medical attention.
Choice D rationale
Painless red vaginal bleeding is indeed a symptom of placenta previa. This bleeding is usually bright red and can occur intermittently or continuously. It is most common in the third trimester of pregnancy.
Correct Answer is C
Explanation
Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.
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