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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Furosemide: Furosemide is a loop diuretic that promotes potassium excretion. It does not need to be withheld for a mildly elevated potassium level; in fact, it may help lower potassium levels in hyperkalemia.
B. Spironolactone: Spironolactone is a potassium-sparing diuretic that can increase serum potassium. With a level of 5.2 mEq/L, administering spironolactone could worsen hyperkalemia and increase the risk of cardiac complications, so the dose should be withheld and the provider notified.
C. Metoprolol: Metoprolol, a beta-blocker, does not typically raise potassium levels significantly. While beta-blockers can slightly affect potassium, withholding is not indicated solely based on a potassium level of 5.2 mEq/L.
D. Atorvastatin: Atorvastatin, a lipid-lowering agent, has no effect on serum potassium levels and does not need to be withheld in this situation. It can be continued safely.
Correct Answer is A
Explanation
A. Perform bimanual fundal massage: Excessive vaginal bleeding postpartum often indicates uterine atony. Performing a bimanual fundal massage helps stimulate uterine contraction, which can reduce hemorrhage. This is a primary and immediate intervention in postpartum bleeding management.
B. Weigh perineal pads: Weighing pads helps quantify blood loss but does not actively stop hemorrhage. While important for assessment and documentation, it is not the first action when the client is actively bleeding.
C. Initiate oxygen at 2 L/min via nasal cannula: Administering oxygen may support tissue oxygenation but does not address the underlying cause of postpartum hemorrhage. Oxygen is supportive care and should not replace interventions to control bleeding.
D. Administer terbutaline: Terbutaline is a uterine relaxant used to treat preterm labor, which would worsen postpartum bleeding by inhibiting uterine contraction. It is contraindicated in cases of active postpartum hemorrhage.
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