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The nurse is continuing to care for the client.

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.

Administer betamethasone.

Give antihypertensive medication.

Monitor intake and output hourly.

Performa vaginal examination every 12 hr.

Obtain a 24-hr urine specimen

Provide a low-stimulation environment

Maintain bed rest

Answer and Explanation

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

A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.

B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.

C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.

D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.

E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.

F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.

G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.

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Correct Answer is B

Explanation

A. "You will have a urine test for the herpes simplex virus": Routine prenatal screening does not include urine testing for herpes simplex virus. Testing for HSV is typically done based on symptoms or history, not as a standard prenatal test.

B. "You will have a rectovaginal culture to test for group B streptococcus.": Group B streptococcus screening is a standard prenatal test performed between 35 and 37 weeks of gestation using a rectovaginal swab. Identifying colonization allows for intrapartum antibiotic prophylaxis to prevent neonatal infection.

C. "You will have a urine test to check for toxoplasmosis": Routine urine testing does not screen for toxoplasmosis. Testing for toxoplasmosis is usually done via blood tests in women at high risk, not standard urine tests.

D. "You will undergo amniotic fluid sampling to test for cytomegalovirus.": Amniocentesis for cytomegalovirus is not part of routine prenatal care and is typically only performed if there is a known risk or suspected fetal infection. Standard prenatal tests focus on more common conditions.

A. Administer an antibiotic to the child for 10 days. B. Cyclophosphamide can be given to decrease the duration of the infection. C. Wear an N95 mask when in direct contact with the child. D. RSV is transmitted by direct contact with respiratory secretions.

Correct Answer is D

Explanation

A. Administer an antibiotic to the child for 10 days: RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics are only indicated if a secondary bacterial infection develops. Routine antibiotic therapy does not treat RSV and should not be included in teaching.

B. Cyclophosphamide can be given to decrease the duration of the infection: Cyclophosphamide is an immunosuppressive chemotherapy agent and has no role in treating RSV. Administering this medication would be inappropriate and harmful in a child with a viral respiratory infection.

C. Wear an N95 mask when in direct contact with the child: Standard precautions for RSV involve contact and droplet precautions, typically including a surgical mask, gloves, and gown. An N95 mask is not required for routine care of RSV, as transmission risk is primarily via contact with secretions and large respiratory droplets.

D. RSV is transmitted by direct contact with respiratory secretions: RSV spreads through close contact with contaminated secretions from coughing, sneezing, or touching surfaces. Teaching guardians about transmission helps prevent spread and reinforces the importance of hand hygiene and infection control measures in the home.

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The nurse is continuing to care for the client. 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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The nurse is continuing to care for the client.

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.