(select all that apply) A nurse is planning care for a client with eclampsia who is scheduled for delivery as soon as possible.
Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Monitor fetal heart rate and uterine activity continuously
Administer oxytocin to augment labor
Maintain a dark and quiet environment
Encourage oral fluids and a high-protein diet
Assess for signs of placental abruption
Correct Answer : A,C
Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension. The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption. The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Statement E is wrong because assessing for signs of placental abruption is not enough. The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women. Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor the client’s deep tendon reflexes hourly because magnesium sulfate can cause neuromuscular blockade and decreased reflexes.The nurse should keep calcium gluconate readily available because it is the antidote for magnesium toxicity.The nurse should maintain a urine output of at least 40 mL/hr because magnesium is excreted by the kidneys and low urine output can indicate renal impairment or fluid overload.The nurse should check the client’s blood pressure every 15 minutes because magnesium sulfate can cause hypotension and preeclampsia can cause hypertension.
Choice D is wrong because the medication should not be infused via a peripheral IV line, but rather through a central line or a large-bore IV catheter to prevent tissue damage.
Correct Answer is C
Explanation
The target blood pressure goal for a client with severe pre-eclampsia is less than 160/110 mmHg.
This is because lowering the blood pressure too much or too fast can compromise the placental perfusion and fetal oxygenation.
Choice A is wrong because it is the target blood pressure goal for a client with chronic hypertension or gestational hypertension without severe features.
Choice B is wrong because it is the target blood pressure goal for a client with mild pre-eclampsia.
Choice D is wrong because it is too high and can increase the risk of maternal and fetal complications such as stroke, eclampsia, placental abruption, and fetal growth restriction.
Normal blood pressure ranges are less than 120/80 mmHg for systolic and diastolic pressures respectively.
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