A nurse is preparing to admit a client with severe preeclampsia.
The healthcare provider's orders include establishing an IV, infusing lactated Ringer's at 125 mL/hour, giving hydralazine 5 mg IVP STAT, and magnesium sulfate 4 grams IV over 20 minutes followed by 2 grams/hour.
What is the primary rationale for these orders?
To prevent fluid overload and decrease cerebral edema.
To manage hypertension and prevent seizures.
To correct anemia and prevent complications.
To reduce the risk of a pulmonary embolism.
The Correct Answer is B
Choice A rationale
While fluid management is a consideration, the orders for IV fluid (lactated Ringer's) at 125 mL/hour are for hydration and to maintain a patent IV access, not primarily to prevent fluid overload. The main goal of the combined therapy with hydralazine and magnesium sulfate is not to decrease cerebral edema but to manage the underlying pathophysiology of preeclampsia.
Choice B rationale
These orders are a classic management approach for severe preeclampsia. Hydralazine is a direct-acting vasodilator used to rapidly decrease blood pressure and prevent stroke. Magnesium sulfate is a central nervous system depressant that raises the seizure threshold, preventing eclamptic seizures, which is the primary goal of its administration.
Choice C rationale
Anemia is not a defining characteristic of preeclampsia, nor is it the primary target of these medications. Preeclampsia involves endothelial cell dysfunction and vasospasm. The prescribed medications, hydralazine and magnesium sulfate, do not treat or prevent anemia. The focus of this treatment plan is managing the key symptoms and preventing the most serious complications.
Choice D rationale
Preeclampsia can increase the risk of coagulopathy, but these orders are not directly aimed at preventing pulmonary embolism. Pulmonary embolism is a risk factor during pregnancy and the postpartum period, but the prescribed medications specifically target the hypertension and risk of seizures associated with severe preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Introducing solid foods at one year of age is too late and may hinder the infant's nutritional development. The American Academy of Pediatrics recommends starting between 4 to 6 months of age when the infant displays readiness cues like head control and interest in food. Waiting too long can lead to nutrient deficiencies, particularly iron, as maternal stores begin to deplete.
Choice B rationale
Introducing new foods one at a time is crucial for identifying potential food allergies or sensitivities. Simultaneous introduction of fruits and vegetables would make it difficult to pinpoint the specific food causing an allergic reaction. This staggered approach, over several days, allows the immune system to acclimate to each new food.
Choice C rationale
Feeding solids from a bottle can lead to overfeeding, as the infant may not be able to regulate intake appropriately. It also bypasses the critical developmental stage of learning to swallow thicker textures and use a spoon. The infant needs to develop oral motor skills and coordination for successful and safe solid food consumption.
Choice D rationale
Introducing new foods one at a time, with a waiting period of 4 to 7 days, is the recommended practice. This method allows the caregiver to easily identify any adverse reactions, such as a rash, diarrhea, or vomiting, associated with a specific food. It's a key strategy for the early detection and management of food allergies.
Correct Answer is ["A","D","F"]
Explanation
Choice A rationale
A trusting relationship is foundational for therapeutic interventions with a child. By building rapport, the nurse creates a safe and secure environment. This allows the child to feel comfortable expressing feelings, anxieties, and fears associated with their health condition and hospitalization. A strong therapeutic alliance enhances cooperation, reduces resistance to care, and improves the overall effectiveness of the treatment plan. Trust is a cornerstone of pediatric nursing.
Choice B rationale
Avoiding mention of the mother may create a sense of abandonment or unimportance for the child, potentially increasing anxiety and emotional distress. Children, even when separated from a parent, need to feel that the parent is still a significant part of their life. This approach can also hinder the child's ability to process their feelings about the separation and can impede effective communication with the nurse. It is not therapeutic.
Choice C rationale
Notifying a parent that social services will be contacted if they do not visit regularly is an inappropriate action for a nurse. This constitutes a threat and is not within the scope of a nurse's role. Such a statement is coercive and unprofessional, potentially damaging the relationship with the family. The nurse's role is to advocate for the child and support the family, not to impose punitive measures. This action is counterproductive to establishing a therapeutic partnership.
Choice D rationale
Bringing a familiar object, such as a favorite toy or blanket, from home provides a transitional object for the child. This object offers a sense of security and continuity with their home environment, which can significantly reduce the stress and anxiety associated with hospitalization. It helps the child feel more in control and comforted in an unfamiliar setting, promoting emotional well-being and making the hospital stay less frightening.
Choice E rationale
A child, especially one who is emotionally distressed or of a young age, lacks the cognitive maturity and legal capacity to enter into a binding treatment contract. This is an inappropriate and unrealistic expectation. It can increase the child's anxiety and lead to feelings of failure if they are unable to comply. The nurse's role is to guide and support the child, not to enforce a formal contract. Informed consent is provided by the parent or legal guardian.
Choice F rationale
Facilitating phone conversations between the child and their mother helps maintain the parent-child bond despite physical separation. Regular communication provides reassurance to the child that they have not been forgotten and helps reduce feelings of abandonment and loneliness. This connection is vital for emotional security and supports the child's coping mechanisms during a stressful hospital stay, promoting a sense of normalcy and continuity of care.
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