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.
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 conducting a gestational age assessment is important, it is not the priority in this situation.
Choice B rationale
Weighing and measuring the newborn are routine procedures, but they are not the priority when the newborn is showing signs of distress.
Choice C rationale
Evaluating the neonatal reflexes’ reactivity is an important part of the newborn assessment, but it is not the priority in this situation.
Choice D rationale
Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.
Correct Answer is B
Explanation
Choice A rationale
Leakage of clear fluid from the breasts towards the end of the second trimester into the third trimester is normal. This fluid is colostrum, a precursor to breastmilk, and its presence indicates breast development in preparation for lactation.
Choice B rationale
An average weight gain during pregnancy is 25 to 35 pounds. In the second trimester, a woman should be gaining about 1 pound per week. A weight gain of 20 pounds by 20 weeks indicates the client is on track or has even gained slightly more than expected. However, further evaluation is important as excessive weight gain in pregnancy might be indicative of underlying conditions such as preeclampsia or gestational diabetes.
Choice C rationale
Fetal movement, also known as quickening, is a normal and expected occurrence around 18-20 weeks' gestation. It is a positive sign of fetal development and well-being.
Choice D rationale
Fundal height is the measure from the pubic symphysis to the top of the uterus. It is an indicator of fetal growth. A fundal height of 20cm at 20 weeks gestation suggests the pregnancy is progressing normally and the baby is growing appropriately.
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