(select all that apply) A nurse is planning care for a client with eclampsia who is scheduled for delivery as soon as possible.
Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Monitor fetal heart rate and uterine activity continuously
Administer oxytocin to augment labor
Maintain a dark and quiet environment
Encourage oral fluids and a high-protein diet
Assess for signs of placental abruption
Correct Answer : A,C
Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension. The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption. The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Statement E is wrong because assessing for signs of placental abruption is not enough. The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women. Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.
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Related Questions
Correct Answer is C
Explanation
C. Fetal heart rate decelerations.
Fetal heart rate decelerations are temporary drops in the fetal heart rate that can indicate fetal distress or lack of oxygen.There are three types of decelerations: early, late and variable.Early decelerations are benign and caused by compression of the fetus’s head during a uterine contraction.Late decelerations are caused by uteroplacental insufficiency, which is a decrease in blood flow to the placenta.Variable decelerations are the most common type and vary in shape, duration and intensity.They are often caused by cord compression or other factors that affect fetal oxygenation.
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A. Fetal heart rate of 140 beats per minute.
Statement is wrong because this is a normal fetal heart rate.The normal range for fetal heart rate is 120-160 beats per minute.
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B. Uterine contractions every 10 minutes.
Statement is wrong because this is a normal frequency for uterine contractions during early labor.
The normal range for uterine contractions is 5-10 minutes apart.
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D. Uterine contractions lasting 60 seconds.
Statement is wrong because this is a normal duration for uterine contractions during active labor.
The normal range for uterine contractions is 45-90 seconds long.
Correct Answer is C
Explanation
Fetal heart rate decelerations indicate a possible compromise of fetal oxygenation and should be reported to the provider immediately.Decelerations can be caused by various factors such as cord compression, uterine hyperstimulation, maternal hypotension, or placental abruption.
Choice A is wrong because a fetal heart rate of 140 beats per minute is within the normal range of 110 to 160 beats per minute.
Choice B is wrong because uterine contractions every 10 minutes are not abnormal in a client with severe pre-eclampsia who is receiving magnesium sulfate.Magnesium sulfate is used to prevent seizures and lower blood pressure in pre-eclampsia, but it does not stop labor.
Choice D is wrong because uterine contractions lasting 60 seconds are not a sign of …
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