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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Perform a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Administer betamethasone.

Monitor intake and output hourly.

Give antihypertensive medication.

Provide a low-stimulation environment

Maintain bed rest.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.

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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential condition: Deep vein thrombosis

Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.

Actions to Take

Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.

Parameters to Monitor

Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.

A. Narrowed pulse pressure B. Tachycardia C. Increasingly severe headache D. Hypotension

Correct Answer is C

Explanation

A. Widened pulse pressure (not narrowed) is associated with increased ICP.

B. Bradycardia (not tachycardia) is commonly seen in increased ICP due to Cushing’s triad.

C. An increasingly severe headache is a key sign of rising ICP due to increased pressure on pain-sensitive structures.

D. Hypertension, not hypotension, is a characteristic of increased ICP.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

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Correct Answer is []

Explanation

A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which in the client's findings are potential indication of increased intracranial pressure?

Correct Answer is C

Explanation

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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.