A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
Continuous fetal monitoring
Ambulate to induce labor
Obtain a daily weight
Assess deep tendon reflexes every hour
The Correct Answer is B
Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.
Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.
Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.
Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.
Choice B reason: Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.
Choice C reason: Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.
Choice D reason: Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.
Correct Answer is D
Explanation
Choice A reason: "I'll basically follow the same diet that I was following before I became pregnant." is an incorrect statement, because it indicates that the client does not understand the need for dietary changes during pregnancy. The client should follow a diet that is individualized, balanced, and consistent in carbohydrate intake, and that meets the nutritional needs of pregnancy.
Choice B reason: "Because I need extra protein, I'll have to increase my intake of milk and meat." is an incorrect statement, because it indicates that the client does not understand the role of protein in diabetes management. The client should consume adequate but not excessive amounts of protein, and choose lean sources of protein, such as poultry, fish, eggs, and legumes.
Choice C reason: "I'll adjust my diet and insulin based on the results of my urine tests for glucose." is an incorrect statement, because it indicates that the client does not understand the limitations of urine tests for glucose. The client should monitor her blood glucose levels regularly, and adjust her diet and insulin accordingly, under the guidance of the provider. Urine tests for glucose are not accurate or reliable indicators of blood glucose levels.
Choice D reason: "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." is a correct statement, because it indicates that the client understands the impact of pregnancy on diabetes. The client should be aware that pregnancy can cause insulin resistance, especially in the second and third trimesters, and that her diet may need to be modified to achieve optimal glycemic control.
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