A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
Restrict protein intake to less than 40 g/day.
Initiate seizure precautions for the client.
Initiate an infusion of 0.9% sodium chloride at 150 ml/hr.
Encourage the client to ambulate twice per day.
The Correct Answer is B
Choice A rationale:
Restricting protein intake to less than 40 g/day is not appropriate for a client with preeclampsia with severe features. While protein restriction might be advised in some cases of preeclampsia, it is not a priority in severe cases where the focus is on managing potential complications.
Choice B rationale:
Initiating seizure precautions is essential in managing a client with preeclampsia with severe features. Preeclampsia can lead to eclampsia, a condition characterized by seizures. Seizure precautions involve implementing measures to prevent injury during a seizure, such as padding the side rails of the bed, ensuring a clear environment, and having emergency equipment readily available.
Choice C rationale:
Initiating an infusion of 0.9% sodium chloride at 150 ml/hr is not directly related to managing preeclampsia with severe features. Although intravenous fluids may be necessary in some cases, the priority in this situation is to prevent and manage potential seizures.
Choice D rationale:
Encouraging the client to ambulate twice per day is not appropriate for a client with preeclampsia with severe features. Bed rest is often recommended in severe cases to reduce stress on the cardiovascular system and decrease the risk of complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
"Retract the foreskin until you feel resistance." This advice is not recommended for newborns with an uncircumcised penis. The foreskin of most male babies doesn't yet pull back (retract) fully at birth, and forcing it back can cause pain, bleeding, and possible damage.
Choice B reason:
"Use a cotton swab to clean under the foreskin." This is not advisable for a newborn's uncircumcised penis. The foreskin is usually still attached to the glans and does not require any special cleaning inside. Using a cotton swab could potentially cause harm by forcing the foreskin back.
Choice C reason:
"Apply petroleum jelly to the foreskin." This instruction is more applicable to a circumcised penis during the healing process to prevent the penis from sticking to the diaper. For an uncircumcised penis, there's no need to apply petroleum jelly as part of regular care.
Choice D reason:
"Wash the penis once per day with soap and water." This is the correct care for an uncircumcised penis. Parents should gently wash the genital area with mild soap and water during bath time without retracting the foreskin.
Correct Answer is D
Explanation
Choice A rationale:
The normal WBC count during pregnancy can vary, but a count of 11,000/mm³ is within an acceptable range. During pregnancy, the WBC count can be slightly elevated due to physiological changes in the body to support the growing fetus.
Choice B rationale:
The normal hemoglobin level during pregnancy is generally around 11 to 12.5 g/dL. Therefore, a hemoglobin level of 11.2 g/dL falls within the normal range, and the nurse does not need to report this finding.
Choice C rationale:
The normal hematocrit (Hct) during pregnancy can vary, but a level of 34% is within the acceptable range. Hct levels can be lower during pregnancy due to increased plasma volume, leading to a mild physiological anemia of pregnancy.
Choice D rationale:
The normal platelet count during pregnancy is typically around 150,000 to 400,000/mm³. With a platelet count of 140,000/mm³, this is slightly below the lower end of the normal range. Thrombocytopenia during pregnancy can increase the risk of bleeding, both during childbirth and postpartum, so the nurse should report this finding to the provider for further evaluation and management.
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