A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.

What intervention should the nurse plan to include in this client’s nursing care plan?

Monitor blood pressure, pulse, and respirations every 4 hours.

Keep an airway at the bedside.

Allow liberal family visitation.

Assess temperature every hour.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While monitoring vital signs is important in a client with eclampsia, it should be done more frequently than every 4 hours due to the risk of seizures and other complications.

Choice B rationale

Keeping an airway at the bedside is crucial for a client with eclampsia. If a seizure occurs, the airway can be used to ensure the client’s airway remains open.

Choice C rationale

Liberal family visitation may not be appropriate for a client with eclampsia who needs a quiet and stress-free environment to prevent triggering seizures.

Choice D rationale

Assessing temperature every hour is not specifically related to the care of a client with eclampsia.

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Correct Answer is D

Explanation

Choice A rationale

While episodes of headache and irritability can occur as side effects of metformin and menotropins, they are not typically severe enough to warrant immediate reporting.

Choice B rationale

Persistent daytime fatigue can be a side effect of these medications, but it is also a common symptom in pregnancy and is not typically a cause for immediate concern.

Choice C rationale

Nausea and vomiting can occur as side effects of these medications. However, they are common side effects and are not typically a cause for immediate concern unless they are severe or persistent.

Choice D rationale

A rapid increase in abdominal girth can be a sign of ovarian hyperstimulation syndrome, a rare but potentially serious side effect of fertility treatments. This condition can cause rapid weight gain, abdominal pain, and bloating, and should be reported immediately.

A. Encourage the mother to breastfeed more frequently. B. Monitor the neonate’s stool and urine output for the last 24 hours. C. Reassure the mother that this is a normal weight loss. D. After verifying the weight’s accuracy, inform the healthcare provider.

Correct Answer is C

Explanation

Choice A rationale

While breastfeeding more frequently can be beneficial for the mother-infant bonding and milk production, it does not directly address the infant’s weight loss.

Choice B rationale

Monitoring the neonate’s stool and urine output for the last 24 hours can provide information about the infant’s hydration status. However, it does not directly address the concern of weight loss.

Choice C rationale

It is normal for newborns to lose some weight in the first few days after birth. This is often due to the loss of excess fluid. A weight loss of up to 10% of the birth weight is generally considered normal in the first week.

Choice D rationale

While it’s important to verify the accuracy of the weight measurement, informing the healthcare provider is not the immediate action required if the weight loss is within the normal range.

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A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.She is not currently convulsing.What intervention should the nurse plan to include in this client’s nursing care plan?

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Naxlex Comprehensive Predictor Exams

A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin.What side effect should the nurse instruct the client to report immediately?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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A 16-year-old client, who is pregnant for the first time and has no children, has been admitted to the hospital with a diagnosis of eclampsia.
She is not currently convulsing.

What intervention should the nurse plan to include in this client’s nursing care plan?