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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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assign the AP to ask the client if she has taken her antidiabetic medication today: Incorrect. Assessing medication use is a nursing responsibility and cannot be delegated to an AP.

B. Determine if the AP has the skills to perform the test: The nurse must ensure that the AP is competent to perform the task safely and accurately before delegation, as part of the nurse's responsibility in delegation.

C. Help the AP perform the blood glucose test: Incorrect. The task should be performed independently by the AP if delegated.

D. Have the AP check the medical record for prior blood glucose test results: Incorrect. Reviewing the medical record is a nursing responsibility and not typically delegated to an AP.

A. The anterior fontanel is open. B. The posterior fontanel is open. C. Both fontanels are the same size. D. Both fontanels show molding.

Correct Answer is A

Explanation

A. The anterior fontanel remains open until about 12-18 months of age, which is expected for an 8-month-old infant.

B. The posterior fontanel usually closes by 2-3 months of age, so it should be closed by 8 months.

C. The anterior and posterior fontanels are different sizes, with the anterior being larger.

D. Molding is typically seen during birth and resolves within a few days.

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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.

Nursing Test Bank

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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.