A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?
Assess deep tendon reflexes every hour
Continuous fetal monitoring
Ambulate twice daily
Obtain a daily weight
The Correct Answer is C
Choice A rationale
Assessing deep tendon reflexes every hour is a common practice in managing severe preeclampsia. Hyperreflexia can be a sign of worsening pre-eclampsia.
Choice B rationale
Continuous fetal monitoring is typically recommended for patients with severe pre-eclampsia. This allows for early detection of fetal distress.
Choice C rationale
Ambulating twice daily may not be appropriate for a patient with severe pre-eclampsia at 35 weeks of gestation. Bed rest is often recommended to help lower blood pressure and reduce the risk of complications.
Choice D rationale
Obtaining a daily weight is a common practice in managing severe pre-eclampsia. Sudden weight gain can be a sign of worsening pre-eclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is to calculate the volume of betamethasone to be drawn up for each dose. The order is to administer betamethasone IM and to repeat the dose after 2 hours. Betamethasone is available as 4mg/mL. Therefore, to administer a dose of 12mg, the nurse would need to draw up 12mg ÷ 4mg/mL = 3mL for each dose.
Correct Answer is C
Explanation
Choice A rationale
The term “effaced” refers to the thinning of the cervix, which is a process that occurs as labor approaches. However, the documentation “-1” does not indicate the degree of cervical effacement.
Choice B rationale
The term “presenting part is 1 cm below the ischial spines” would be documented as “+1” in a vaginal examination. This indicates that the presenting part of the fetus (usually the head) is 1 cm below the ischial spines, which are bony landmarks in the maternal pelvis.
Choice C rationale
The documentation “-1” in a vaginal examination refers to the position of the presenting part of the fetus in relation to the ischial spines of the maternal pelvis. A “-1” indicates that the presenting part is 1 cm above the ischial spines. This is a common finding during labor and does not indicate any abnormality.
Choice D rationale
The term “dilated” refers to the opening of the cervix. In the context of labor and delivery, the cervix dilates from 0 to 10 cm to allow for the passage of the baby. However, the documentation “-1” does not provide information about the degree of cervical dilation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.