A nurse is caring for a client who is pregnant.
Complete the following sentence by using the lists of options.
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should first assist with is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
This question focuses on prioritization of care for a pregnant client with severe preeclampsia. The client presents with severe hypertension, proteinuria, hyperreflexia, thrombocytopenia, and elevated liver enzymes, all consistent with preeclampsia with severe features. The provider has initiated magnesium sulfate, antihypertensives, corticosteroids for fetal lung maturity, and continuous fetal monitoring. The nurse must prioritize interventions that prevent maternal neurologic deterioration (eclampsia) while simultaneously ensuring fetal well-being through continuous assessment. Safety and rapid recognition of deterioration in both mother and fetus are the highest priorities.
Rationale for correct choices:
• Implementing seizure precautions: The client is at high risk for eclampsia due to severe preeclampsia, evidenced by severe hypertension, headache, and hyperreflexia. Seizure precautions are the first priority because seizures can lead to maternal hypoxia, fetal distress, placental abruption, and even maternal and fetal death. Interventions include padding side rails, maintaining a low-stimulation environment, keeping oxygen and suction at the bedside, and ensuring IV access is patent. Magnesium sulfate therapy is also initiated to prevent seizure activity, but safety precautions must be in place immediately.
• Reviewing fetal heart rate tracing: After initiating maternal safety measures, the nurse must assess fetal well-being because severe preeclampsia significantly increases the risk of placental insufficiency and fetal hypoxia. Continuous fetal monitoring is ordered due to the risk of decreased placental perfusion. Evaluating baseline heart rate, variability, and accelerations helps determine fetal tolerance to the intrauterine environment. Early identification of fetal compromise allows timely obstetric intervention, including possible delivery.
Rationale for incorrect choices:
• Administering betamethasone IM: Betamethasone is important for promoting fetal lung maturity in anticipation of possible preterm delivery, but it is not the first priority. Maternal stabilization and prevention of seizures take precedence before elective medications. While it improves neonatal outcomes, it does not address the immediate life-threatening risks of eclampsia. It should be administered after safety and monitoring priorities are established.
• Inserting an indwelling urinary catheter: A urinary catheter is important for strict input and output monitoring, especially to assess renal perfusion and urine output during magnesium sulfate therapy. However, it is not the immediate first action compared to seizure prevention and fetal assessment. Maternal neurologic stability must be ensured before procedural tasks.
• Administering acetaminophen PO: Acetaminophen may help reduce headache discomfort, but it does not treat the underlying cause of severe preeclampsia or prevent seizures. Pain control is not the priority in a life-threatening hypertensive emergency. The client’s neurological and vascular status requires urgent intervention before symptom relief. Therefore, this is a lower-priority action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Methicillin-resistant Staphylococcus aureus (MRSA) is a highly resistant bacterial infection transmitted primarily through direct contact with contaminated hands, surfaces, or equipment. Medical asepsis focuses on reducing and preventing the spread of microorganisms through proper hygiene and infection-control practices. Hand hygiene remains the single most effective intervention for preventing transmission of MRSA in healthcare settings. Nurses must consistently apply standard and contact precautions to protect both clients and healthcare personnel.
Rationale:
A. Wearing a mask while providing activities of daily living is not routinely required for MRSA because the organism is primarily spread through contact rather than airborne transmission. Masks are generally reserved for procedures that may generate respiratory droplets or if the client has a concurrent respiratory infection. Contact precautions focus more on gloves, gowns, and hand hygiene.
B. Washing hands for at least 15 seconds before providing care is correct because effective hand hygiene significantly reduces transmission of MRSA between clients and healthcare workers. Proper washing removes transient organisms from the skin and interrupts contact spread. Hand hygiene should be performed before and after client contact and after glove removal.
C. Using a 40% alcohol-based hand product is incorrect because alcohol-based hand rubs should contain at least 60% alcohol to effectively reduce microbial contamination. Lower concentrations are less effective against many pathogens and do not meet recommended infection-control standards.
D. Providing the client with a mask during clinical visits is not routinely necessary for MRSA because transmission occurs mainly through direct contact, not respiratory droplets. Masks are more appropriate for airborne or droplet precautions. Contact isolation measures are the priority for MRSA management.
Correct Answer is A
Explanation
ACE inhibitors are commonly prescribed antihypertensive medications that reduce blood pressure by blocking the conversion of angiotensin I to angiotensin II, leading to vasodilation and decreased peripheral resistance. A common early adverse effect is orthostatic hypotension, which can cause dizziness or lightheadedness when standing due to sudden drops in blood pressure. Patient education focuses on safety measures, gradual position changes, and monitoring for side effects. Proper teaching helps prevent falls and improves medication adherence.
Rationale:
A. Sitting back down when lightheadedness occurs is appropriate because it helps restore cerebral perfusion and reduces the risk of falls. This is a key safety strategy for managing orthostatic hypotension associated with ACE inhibitor therapy. Clients should also be taught to rise slowly from sitting or lying positions to minimize symptoms.
B. Restricting fluid intake is incorrect because dehydration can worsen orthostatic hypotension by reducing circulating blood volume. Adequate hydration helps maintain blood pressure stability and reduces dizziness. Fluid restriction would therefore increase the risk of adverse effects.
C. Taking a daily potassium supplement is incorrect because ACE inhibitors can increase potassium levels, leading to hyperkalemia. Supplementation without medical indication may result in dangerous cardiac dysrhythmias. Potassium levels should be monitored rather than routinely supplemented.
D. Discontinuing the medication if symptoms occur again is inappropriate because orthostatic hypotension is a common early side effect that often improves with time and proper management. Abrupt discontinuation can lead to uncontrolled hypertension and increased cardiovascular risk. The provider should be notified if symptoms persist or worsen, rather than stopping the medication independently.
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