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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 C

Explanation

A. Assault: Assault involves the threat or attempt to cause harm that makes the client fear imminent injury. Hiding the client’s car keys does not involve a threat or intimidation, so it does not meet the criteria for assault.

B. Negligence: Negligence involves failing to provide the standard of care, resulting in harm. While hiding the keys is inappropriate, it is an intentional act rather than a failure to act, so it is not classified as negligence.

C. False imprisonment: False imprisonment occurs when a person is intentionally restrained or confined without legal authority or consent. By hiding the client’s car keys to prevent them from leaving, the AP is restricting the client’s freedom of movement, fulfilling the criteria for false imprisonment.

D. Battery: Battery involves intentional physical contact that is harmful or offensive. Hiding car keys does not involve direct physical contact with the client, so it does not constitute battery.

A. Client reports popping sensation at the wound B. Client is tender to touch at the surgical site C. Crusting on the client's incision line D. serosanguineous drainage on the client's dressing

Correct Answer is A

Explanation

A. Client reports popping sensation at the wound: A popping or tearing sensation at the surgical site can indicate wound dehiscence or evisceration, which is a surgical emergency. Immediate reporting to the provider is essential for prompt intervention to prevent further complications.

B. Client is tender to touch at the surgical site: Mild tenderness is expected 24 hours postoperatively due to inflammation and tissue trauma. While it should be monitored, it is not an urgent finding requiring immediate provider notification.

C. Crusting on the client's incision line: Light crusting is a normal part of the healing process and does not typically indicate a complication. Routine wound care and monitoring are sufficient.

D. Serosanguineous drainage on the client's dressing: Serosanguineous drainage is expected within the first 24–48 hours after surgery. It is a normal finding and usually does not require urgent reporting unless it increases significantly or changes character.

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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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Correct Answer is C

Explanation

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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.