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The nurse continues to care for the client who is at 30 weeks of gestation.

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.

Encourage bed rest.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A: This could be a sign of preeclampsia, a serious condition that requires immediate medical attention due to its potential to cause high blood pressure, proteinuria, and seizures, affecting both the mother and fetus.
B: Urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus; it's not typically a concern unless accompanied by pain or other symptoms.

C: Faintness upon rising can be related to changes in blood pressure or blood volume during pregnancy, but it's not specific to the second trimester and is often transient.This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
D: Bleeding gums are also a common symptom due to hormonal changes increasing blood flow to the gums, and while it should be monitored, it is not typically a cause for alarm unless accompanied by other symptoms.

A. Maintain eye contact with the newborn during feedings. B. Minimize noise in the newborn's environment. C. Administer naloxone to the newborn. D. Swaddle the newborn with his legs extended.

Correct Answer is B

Explanation

A. While maintaining eye contact during feedings can foster bonding and comfort, it is not specifically beneficial for managing symptoms of neonatal abstinence syndrome (NAS).
B. Minimizing noise in the newborn's environment is crucial for a baby with NAS. These infants often have increased sensitivity to stimulation and can become easily agitated. A quiet, calming environment can help soothe them.
C. Administering naloxone to a newborn with NAS is not recommended. Naloxone is an opioid antagonist and, while it can reverse opioid effects acutely, it is not a treatment for the withdrawal symptoms associated with NAS.
D. Swaddling the newborn is beneficial, but the legs should not be extended.

Swaddling should allow for some movement of the legs and hips to prevent the development of hip dysplasia. Swaddling in a way that allows the legs to bend and move is generally recommended.

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The nurse continues to care for the client who is at 30 weeks of gestation. 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.

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The nurse continues to care for the client who is at 30 weeks of gestation.

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.