A client who is 38 weeks pregnant is being monitored for pre-eclampsia.
She suddenly complains of continuous abdominal pain and vaginal bleeding.
Which of the following nursing interventions should not be included in the care of this client?
Reassure the patient that she will deliver vaginally.
Insert an indwelling Foley catheter.
Initiate IV therapy with Lactated Ringer's solution.
Monitor the fetal heart tracing.
The Correct Answer is A
Choice A rationale
Reassuring the patient that she will deliver vaginally is inappropriate and could be misleading, especially if there are complications such as placental abruption or severe pre-eclampsia, which may necessitate a cesarean delivery for the safety of the mother and baby.
Choice B rationale
Inserting an indwelling Foley catheter is a standard procedure to monitor urine output and kidney function, especially in cases of pre-eclampsia, where accurate monitoring of fluid balance is crucial.
Choice C rationale
Initiating IV therapy with Lactated Ringer's solution is important to maintain maternal hydration and electrolyte balance, especially if the client is experiencing blood loss and is at risk of hypovolemia.
Choice D rationale
Monitoring the fetal heart tracing is essential to assess the baby's well-being. Continuous fetal monitoring helps detect signs of fetal distress, allowing for timely interventions to ensure the safety of both mother and baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","F","G"]
Explanation
Choice A rationale
Respiratory rate of 8 breaths per minute indicates respiratory depression, a serious adverse effect of magnesium sulfate toxicity. Magnesium sulfate can depress neuromuscular transmission, leading to decreased respiratory effort and rate.
Choice B rationale
Blood pressure of 150/90 mmHg is not indicative of magnesium sulfate toxicity. Elevated blood pressure is a symptom of pre-eclampsia and not directly related to the adverse effects of magnesium sulfate. Therefore, it does not indicate toxicity.
Choice C rationale
Lung crackles are typically associated with fluid overload or heart failure rather than magnesium sulfate toxicity. While it is a serious condition, it is not specifically an adverse effect of magnesium sulfate.
Choice D rationale
Increase in fetal heart rate is not a common adverse effect of magnesium sulfate. Fetal heart rate changes are more commonly related to the underlying maternal condition or other medications used in pregnancy rather than magnesium sulfate.
Choice E rationale
Deep tendon reflexes would typically be decreased or absent in magnesium sulfate toxicity. Therefore, presence of deep tendon reflexes would not indicate an adverse effect of magnesium sulfate.
Choice F rationale
Confusion can occur due to central nervous system depression caused by high levels of magnesium sulfate. This is a significant adverse effect indicating possible toxicity.
Choice G rationale
Urine output of 30 mL in 2 hours suggests oliguria, which can be a sign of magnesium sulfate toxicity as the drug is excreted through the kidneys. Reduced urine output can indicate the kidneys are not clearing the drug efficiently, leading to toxicity.
Correct Answer is B
Explanation
Choice A rationale
Increased fetal movement is normal and usually not a sign to head to the hospital unless there are other concerns.
Choice B rationale
Ruptured membranes can signify the beginning of labor or risk for infection, warranting a visit to the hospital for assessment.
Choice C rationale
Contractions that are 10 minutes apart typically indicate early labor, but not necessarily the need to go to the hospital immediately.
Choice D rationale
Mild abdominal or groin discomfort can occur during pregnancy and does not immediately warrant a hospital visit without other signs of labor.
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