Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A: Changing the TPN bag and tubing every 24 hours is standard practice to prevent infection, so this action is appropriate.
B: Checking glucose levels every 6 hours is necessary because TPN can significantly affect blood glucose levels.
C: Gradually increasing the TPN rate is a standard procedure to monitor tolerance to the infusion.
D: This indicates a need for intervention. TPN lines should not be used for any other infusions to prevent contamination and interactions between the nutrition formula and medications.

A. Painful, tender breast B. Temperature C. Chills D. Foul-smelling lochia

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Mastitis: A, B, C

Endometritis: B, C, D

Rationale:
A. This finding is consistent with mastitis. Mastitis is characterized by inflammation of the breast tissue, often presenting with pain, tenderness, warmth, and redness in the affected breast.
B. This finding can be indicative of both mastitis and endometritis. A fever, as indicated by an elevated temperature (38.8°C or 101.9°F), is a common symptom of both mastitis and endometritis. It suggests an inflammatory response or infection in the body.
C. This finding is also consistent with both mastitis and endometritis. Chills often accompany fever and can be a sign of systemic infection or inflammation.
D. This finding is more indicative of endometritis. Endometritis involves infection or inflammation of the uterine lining, which can result in foul-smelling lochia. Foul- smelling lochia may indicate the presence of infection within the uterus.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse who is administering total parenteral nutrition (TPN) to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

Correct Answer is D

Explanation

A nurse is caring for a client who is 4 days postpartum following a cesarean birth Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?

A nurse is teaching a client about family planning using the basal body temperature method. Which of the following Instructions should the nurse include in the teaching?

A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include?

A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

A nurse is preparing to administer PRN pain medication to a client who has cholelithiasis and is experiencing moderate abdominal pain. Which of the following medications should the nurse plan to administer?

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

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.