The nurse continues to care for the client who is at 30 weeks of gestation.
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.
Encourage 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. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.
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. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.
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 ["B","C","E","F"]
Explanation
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
Correct Answer is ["B","C","E","F"]
Explanation
A. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infection.
B. Loose-fitting clothing allows for better air circulation and can help prevent discomfort and irritation, especially with increased sweating and vaginal discharge during pregnancy.
C. Flat or low-heeled shoes provide better support and stability, reducing the strain on the back and pelvis, which can alleviate backaches common during pregnancy.
D. Hot showers can exacerbate itching, especially if the skin is already irritated.
Lukewarm or cool showers are preferable for relieving itching.
E. Fried foods can contribute to heartburn and indigestion, which are common during pregnancy due to hormonal changes and increased pressure on the stomach from the growing uterus.
F. An abdominal support belt can help alleviate backaches by providing additional support to the abdomen and reducing strain on the back muscles.
G. Eating frequent, smaller meals throughout the day is recommended during pregnancy to help manage heartburn, prevent overeating, and maintain stable blood sugar levels.
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