A nurse is caring for a client who is 34 weeks pregnant.
The nurse is reviewing the client’s electronic medical record to develop a care plan.
The nurse should take which of the following actions to address the condition the client is most likely experiencing, and monitor which parameters to assess the client’s progress.
Implement seizure precautions.
Check deep tendon reflexes every hour.
Administer prescribed methyldopa.
Monitor neurologic status.
The Correct Answer is A
Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.
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Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.
Correct Answer is ["-"]
Explanation
The nurse is observing a potential case of shoulder dystocia, a condition where the baby’s head has been delivered but one of the shoulders becomes stuck behind the mother’s pelvic bone. The nurse should monitor the mother’s vital signs and the baby’s heart rate. The nurse should call for immediate assistance, perform maneuvers to help deliver the baby, and prepare for a potential emergency cesarean section if necessary.
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