Exhibits
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
Initiate contact precautions.
Check urinary output.
Decrease lighting in the client's room.
Monitor blood pressure.
Prepare for amniocentesis.
Apply Internal fetal monitor.
Assess DTR.
Get bed rest.
Correct Answer : B,C,D,G,H
A. Contact precautions are not indicated based on the assessment findings provided.
Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.
C. a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F. Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Flushing the tube with water after feedings helps to prevent tube clogging and ensures adequate delivery of enteral feedings. However, it does not address the diarrhea.
B. While it's important to discard open cans of formula within a specified timeframe to prevent bacterial growth, diarrhea in the client is not directly addressed by discarding formula after 36 hours.
C. The nurse should consider administering feedings at a slower rate to manage diarrhea. This approach can help reduce the incidence of diarrhea as it allows for better absorption of the nutrients.
D. Providing chilled formula is not typically indicated for clients with diarrhea and may not be well-tolerated.
Correct Answer is []
Explanation
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
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