A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.

Apply internal fetal monitor.

Prepare client for dilation and curettage with suction

Administer 1 hr glucose tolerance test

Refer client to perinatal loss support group

Provide the client with instructions on medroxyprogesterone therapy.

Administer Rho (D) immune globulin

Answer and Explanation

Correct Answer : B,D,F

A. Apply internal fetal monitor: An internal fetal monitor is used to assess fetal heart rate and contractions in a viable pregnancy. In this case, the client has a molar pregnancy with no viable fetus, so fetal monitoring is not appropriate and provides no clinical benefit.

B. Prepare client for dilation and curettage with suction: Suction dilation and curettage (D&C) is the primary treatment for a molar pregnancy to remove abnormal trophoblastic tissue. Planning for this procedure is essential to prevent complications such as hemorrhage, persistent gestational trophoblastic disease, and infection.

C. Administer 1 hr glucose tolerance test: Glucose screening is not indicated at this time. The client is only 20 weeks gestation and is being managed for a molar pregnancy, not for routine prenatal care or gestational diabetes screening. This test is not a priority.

D. Refer client to perinatal loss support group: A molar pregnancy is considered a pregnancy loss, and the client may experience emotional distress. Referral to a perinatal loss support group provides psychological support and helps the client cope with grief and anxiety associated with this event.

E. Provide the client with instructions on medroxyprogesterone therapy: Medroxyprogesterone therapy is not indicated for managing a molar pregnancy. Contraception may be discussed after treatment, but this is not an immediate priority during acute management of the condition.

F. Administer Rho(D) immune globulin: The client is Rh-negative, and any procedure that may cause fetomaternal hemorrhage, such as D&C, requires administration of Rho(D) immune globulin to prevent isoimmunization in future pregnancies. This is a critical prophylactic intervention in Rh-negative clients.

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Correct Answer is A

Explanation

A. Tetany: Calcium is essential for proper neuromuscular function. A deficiency can lead to increased neuromuscular excitability, resulting in muscle spasms, cramps, and tetany, which are hallmark signs of hypocalcemia.

B. Anemia: Anemia is typically related to deficiencies in iron, vitamin B12, or folate, not calcium. While calcium plays roles in other body functions, it is not a direct factor in hemoglobin synthesis or red blood cell production.

C. Kidney stones: Kidney stones are more commonly associated with hypercalcemia or high calcium excretion rather than calcium deficiency. Low calcium intake may actually increase oxalate absorption, but it is not a direct cause of stones.

D. Osteoarthritis: Osteoarthritis is a degenerative joint disease influenced by age, joint stress, and cartilage wear. Calcium deficiency affects bone density (leading to osteoporosis) rather than the cartilage degeneration seen in osteoarthritis.

A. Encourage the client to talk about their feelings B. Assure the client that they are in a safe place. C. Promote problem-solving with the client D. Explore behaviors that have worked to relieve anxiety in the past

Correct Answer is B

Explanation

A. Encourage the client to talk about their feelings: During a panic attack, clients are often overwhelmed and unable to process or articulate feelings. Encouraging discussion is helpful later but is not the first priority during acute panic.

B. Assure the client that they are in a safe place: Ensuring the client feels safe addresses immediate anxiety and establishes a calming environment. Safety and emotional stabilization are the first priorities according to the nursing process when managing acute panic attacks.

C. Promote problem-solving with the client: Problem-solving requires cognitive processing, which is impaired during a panic attack. This intervention is appropriate after the client has calmed and is able to think clearly.

D. Explore behaviors that have worked to relieve anxiety in the past: Reviewing coping strategies is useful once the client’s acute panic symptoms are under control. It is not the immediate priority compared with ensuring safety and reducing immediate fear.

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A nurse is caring for a client who is at 20 weeks of gestation

Which of the following actions should the nurse plan to take? Select all that apply.