A nurse is assisting with the care of a client who has preeclampsia.
Complete the following sentence by using the lists of options
The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
- Blood pressure. The client’s blood pressure is severely elevated (162/110 mm Hg), indicating severe preeclampsia. Uncontrolled hypertension increases the risk of stroke, placental abruption, and eclampsia (seizures). Immediate interventions such as antihypertensive medications (e.g., labetalol or hydralazine) should be initiated to lower blood pressure and prevent complications.
- Respiratory rate. The client’s respiratory rate is 20/min, which is within the normal range (12–20/min). There is no indication of respiratory distress or compromise, making this a lower priority.
- Deep tendon reflexes. The client has 3+ deep tendon reflexes, which suggest neuromuscular irritability, a sign of worsening preeclampsia. However, while hyperreflexia is concerning, severe hypertension poses a more immediate risk of stroke or seizure, making it the first priority.
- Platelet count. The client’s platelet count is critically low (95,000/mm³), which is a hallmark of HELLP syndrome (Hemolysis, Elevated Liver Enzymes, and Low Platelets). Low platelets increase the risk of bleeding complications, particularly in cases of delivery, epidural anesthesia, or cesarean section. Monitoring for further platelet decline and signs of HELLP progression (right upper quadrant pain, worsening liver function, or increased hemolysis) is essential.
- Hematocrit. The client’s hematocrit is 35%, which is within the normal range for pregnancy (33–47%). Although anemia is present (Hgb 10 g/dL), it is not an immediate life-threatening concern, making it a lower priority than the platelet count.
- Peripheral edema. The client has +2 pitting edema, which is common in preeclampsia, but it is not as critical as severe hypertension or thrombocytopenia. While worsening edema can indicate fluid retention and organ dysfunction, it does not require immediate intervention compared to other findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Lie in a left side-lying position for 30 min after meals. While lying on the left side can help reduce reflux compared to lying on the right, it is still recommended to remain upright for at least 30 to 60 minutes after meals to allow proper digestion and prevent acid from flowing back into the esophagus. Lying down too soon after eating, regardless of position, can worsen heartburn.
B. Eat three large meals per day. Large meals can increase stomach pressure and worsen heartburn. Eating smaller, more frequent meals throughout the day helps reduce gastric distension and minimizes acid reflux episodes.
C. Drink a cup of black coffee before breakfast. Coffee is acidic and can relax the lower esophageal sphincter, increasing the likelihood of heartburn. Pregnant clients should limit caffeine and avoid acidic or spicy foods that may trigger reflux symptoms.
D. Take sips of milk between meals. Milk can temporarily neutralize stomach acid and provide relief from heartburn. Drinking small sips between meals, rather than consuming large amounts at once, helps prevent stomach overfilling, which can contribute to reflux.
Correct Answer is D
Explanation
A. "You will be prescribed diazepam." Diazepam is a benzodiazepine used for anxiety and seizures, but it is not the recommended treatment for opioid use disorder in pregnancy. Prolonged use can lead to neonatal withdrawal symptoms, respiratory depression, and sedation. Additionally, benzodiazepine dependence can develop, complicating the management of opioid withdrawal.
B. "You will be prescribed naloxone." Naloxone is an opioid antagonist used for reversing opioid overdose, but it is not appropriate for long-term treatment of opioid use disorder. When administered to an opioid-dependent pregnant client, naloxone can induce sudden withdrawal, increasing the risk of fetal distress, uterine contractions, and preterm labor. Instead, opioid agonist therapy with methadone or buprenorphine is preferred.
C. "You will be prescribed aripiprazole." Aripiprazole is an atypical antipsychotic used for conditions such as schizophrenia, bipolar disorder, and depression. It has no role in managing opioid dependence, as it does not reduce opioid cravings or withdrawal symptoms. While some clients with opioid use disorder may have coexisting psychiatric conditions requiring antipsychotics, aripiprazole alone does not address opioid addiction.
D. "You will be prescribed methadone." Methadone is the standard treatment for opioid use disorder in pregnancy because it stabilizes opioid levels, preventing withdrawal symptoms and reducing cravings. This approach minimizes the risks of fetal distress, miscarriage, and preterm labor. Methadone maintenance also lowers the likelihood of illicit opioid use, improving prenatal care engagement and neonatal outcomes.
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