A nurse in a provider’s office is reinforcing teaching about home care to a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching? Choice Options:
Perform daily fetal movement counts.
Limit fluid intake to 1,000 ml/day.
Limit sodium intake to 2,000 mg/day.
Rest in bed in the supine position.
The Correct Answer is A
Choice A rationale:
Fetal movement counts are a simple yet effective tool to monitor fetal well-being in women with preeclampsia. They provide valuable insights into the baby's activity level and can alert the healthcare team to potential concerns early on.
Preeclampsia can compromise placental blood flow, which can lead to decreased fetal movement. By tracking fetal movements daily, the mother can detect any significant changes or reductions in activity, prompting further assessment and intervention if necessary.
Research has shown that regular fetal movement counts can reduce the risk of stillbirth in women with preeclampsia. This is because prompt recognition of decreased fetal movements allows for timely interventions, such as closer monitoring, induction of labor, or delivery, to prevent adverse outcomes.
Daily fetal movement counts empower women to take an active role in their pregnancy care and contribute to a sense of control in a condition that can often feel unpredictable. This increased involvement can promote maternal-fetal bonding and reduce anxiety.
Choice B rationale:
While fluid restriction has been a traditional recommendation for preeclampsia, current evidence does not support limiting fluid intake to 1,000 ml/day. In fact, excessive fluid restriction can lead to dehydration, which can worsen placental perfusion and compromise fetal well-being.
It's essential for women with preeclampsia to maintain adequate hydration to support essential bodily functions and fetal growth. Adequate fluid intake also helps to prevent urinary tract infections, which are more common in women with preeclampsia.
Choice C rationale:
Although reducing sodium intake can be beneficial for overall blood pressure control, there's insufficient evidence to support a strict sodium restriction of 2,000 mg/day specifically for managing mild preeclampsia. Individual needs may vary, and a more moderate approach to sodium reduction is often recommended.
Focusing on a balanced, healthy diet with appropriate sodium intake is generally more effective than strict limitations. This approach promotes overall well-being and supports healthy blood pressure levels without compromising nutritional needs. Choice D rationale:
Rest is often recommended for women with preeclampsia to reduce stress on the cardiovascular system and promote placental blood flow. However, the supine position (lying on the back) is not ideal, as it can further compress the large blood vessels in the abdomen and potentially reduce blood flow to the placenta.
Side-lying positions, particularly the left lateral position, are preferred for women with preeclampsia. These positions help to alleviate pressure on the major blood vessels, enhance blood flow, and improve uteroplacental circulation, which benefits both the mother and the baby.
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Related Questions
Correct Answer is B
Explanation
Choice A:
Applying ice to the perineal area is not a recommended intervention for suspected placenta previa. While ice can help reduce swelling and pain in some cases, it does not address the underlying concern of potential placental bleeding.
Focusing on external monitoring for fetal well-being and avoiding any actions that could disrupt the placenta are the priorities in this situation.
Choice C:
Completing a vaginal exam is contraindicated in suspected placenta previa. Inserting fingers into the vagina can disrupt the placenta and potentially cause heavy bleeding, increasing the risk of preterm labor, fetal distress, or maternal hemorrhage. Non-invasive assessment methods are crucial to protect the placenta and prevent complications.
Choice D:
Performing a rectal exam is also not indicated for suspected placenta previa. It does not provide information about the placental position and could potentially stimulate contractions, which are undesirable in this situation.
External fetal monitoring is a safer and more informative approach.
Choice B:
Applying an external fetal monitor is the most appropriate action for a nurse caring for a client with suspected placenta previa. It allows for continuous assessment of fetal heart rate and activity, which can help detect any signs of fetal distress or placental abruption.
It is a non-invasive method that does not carry the risks associated with vaginal or rectal exams.
Early identification of any fetal compromise can lead to prompt interventions to ensure the best possible outcomes for both mother and baby.
Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 60/min is a sign of bradycardia, which can be a side effect of magnesium sulfate toxicity. Magnesium sulfate slows down neuromuscular transmission, which can lead to a decrease in heart rate. If the heart rate drops too low, it can compromise blood flow to vital organs, including the brain and heart. Therefore, a heart rate of 60/min is not a safe finding that would indicate the nurse should continue the infusion.
Choice C rationale:
A urine output of 50 ml in 4 hours is indicative of oliguria, which is a decreased urine output. Oliguria can be a sign of magnesium sulfate toxicity, as magnesium is primarily excreted through the kidneys. If the kidneys are not functioning properly, magnesium can build up in the body and lead to toxic levels. Therefore, a urine output of 50 ml in 4 hours is not a safe finding that would indicate the nurse should continue the infusion.
Choice D rationale:
Diminished deep-tendon reflexes are another sign of magnesium sulfate toxicity. Magnesium sulfate suppresses the nervous system, which can lead to decreased reflexes. If the reflexes are too diminished, it can indicate that the magnesium level in the body is too high. Therefore, diminished deep-tendon reflexes are not a safe finding that would indicate the nurse should continue the infusion.
Choice B rationale:
A respiratory rate of 16/min is within the normal range for an adult. It does not indicate any respiratory depression, which can be a side effect of magnesium sulfate toxicity. Therefore, a respiratory rate of 16/min is a safe finding that would indicate the nurse can continue the infusion.
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