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 B
Explanation
Choice A rationale
Missing a menstrual cycle and reporting vaginal spotting could indicate early pregnancy or other non-emergency conditions. While this client should be evaluated, it is not the highest priority.
Choice B rationale
A client at 28 weeks of gestation reporting painless vaginal bleeding could be experiencing placenta previa or placental abruption, both of which are obstetric emergencies. This client should be prioritized for immediate evaluation.
Choice C rationale
A client at 38 weeks of gestation reporting symptoms of a cough and fever may have an upper respiratory infection. While this should be evaluated, it is not the highest priority unless the client is in distress.
Choice D rationale
Nausea and vomiting are common in early pregnancy. A client at 14 weeks of gestation reporting these symptoms would need evaluation, but it is not the highest priority.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.
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