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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.

Give antihypertensive medication.

Perform a vaginal examination every 12 hr.

Provide a low-stimulation environment.

Administer betamethasone.

Obtain a 24-hr urine specimen.

Monitor intake and output hourly.

Maintain bed rest.

Answer and Explanation

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

The correct answers are Choices A, C, D, E, F, and G.

Choice A rationale: Antihypertensive medication is indicated due to sustained elevated BP (≥160/110 mm Hg), which increases risk for stroke, placental abruption, and eclampsia. Prompt control reduces maternal and fetal morbidity.

Choice B rationale: Routine vaginal exams are contraindicated unless signs of labor are present. Frequent exams increase infection risk and are not part of standard care for hypertensive or preeclamptic clients.

Choice C rationale: A low-stimulation environment (dim lights, quiet room) reduces CNS irritability and seizure risk in preeclampsia. It supports neuroprotection and aligns with seizure precaution protocols.

Choice D rationale: Betamethasone promotes fetal lung maturity in preterm gestation when delivery is likely. It reduces neonatal respiratory distress syndrome and improves outcomes in hypertensive pregnancies.

Choice E rationale: A 24-hour urine specimen quantifies proteinuria, essential for diagnosing preeclampsia severity. Protein 3+ on dipstick warrants confirmation via timed collection for accurate staging.

Choice F rationale: Hourly intake and output monitoring detects fluid shifts, renal compromise, and early signs of pulmonary edema. It’s critical in hypertensive disorders to guide fluid management.

Choice G rationale: Bed rest minimizes physical stress, stabilizes BP, and reduces risk of placental disruption. Left lateral positioning enhances uteroplacental perfusion and supports fetal oxygenation.

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Correct Answer is B

Explanation

Choice A rationale:

Having the client exhale deeper than she inhales is a breathing technique that can help manage pain but does not specifically address the request for pain management techniques during natural childbirth. Option A does not provide comprehensive information about pain management strategies during labor.

Choice B rationale:

Providing information about the use of hydrotherapy during labor is a valid suggestion. Hydrotherapy, such as taking a warm bath or using a shower during labor, can help alleviate pain and promote relaxation. It is a non-pharmacological pain management option that the client can consider.

Choice C rationale:

Encouraging the client to have the family exit the room when the pain is unbearable may offer emotional support, but it does not provide a direct pain management technique. Additionally, the presence of loved ones can be a source of comfort for the client during labor.

Choice D rationale:

Informing the client that using pharmacological pain management will not impact the delivery is a true statement. Pharmacological pain relief methods, such as epidural anesthesia, do not affect the progress of labor or the outcome of delivery. However, this option does not provide an alternative pain management technique for the client who desires natural childbirth.

A. Provide a verbal report of the client's condition to the paramedic performing the transfer. B. Fax the client's name and identifiable information to the rehabilitation facility. C. Email the client's health information to the facility in an unencrypted file. D. Discuss the client's response to the transfer with another staff nurse.

Correct Answer is A

Explanation

Choice A rationale:

Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.

Choice B rationale:

Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.

Choice C rationale:

Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.

Choice D rationale:

Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth.Which of the following pain management techniques should the nurse suggest?

Correct Answer is B

Explanation

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Correct Answer is A

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.