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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Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Correct Answer is []
Explanation
The client is most likely experiencing Normal labor progression. The retraction of the fetal head against the maternal perineum, regular and progressing contractions, and full dilation of the cervix are all signs of normal labor progression.
Actions: The nurse should:
1. Encourage the client to push during contractions. This will help the baby move down the birth canal.
2. Monitor fetal heart rate. This is crucial to ensure the baby is not in distress.
Parameters: The nurse should monitor:
1. Frequency of contractions. This will help assess the progress of labor.
2. Fetal heart rate. Any abnormalities could indicate fetal distress, which would require immediate medical attention.
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