(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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Two or more accelerations of at least 15 beats/min above baseline lasting for at least 15 seconds in a 20-minute period.This indicates a reactive test, which means that the fetus is well oxygenated and not in distress.
Choice B is wrong because no accelerations or decelerations in a 20-minute period indicate a non-reactive test, which may suggest fetal hypoxia or acidosis.
Choice C is wrong because one acceleration of at least 10 beats/min above baseline lasting for at least 10 seconds in a 20-minute period is the criterion for a reactive test for gestational age less than 32 weeks, not 34 weeks.
Choice D is wrong because variable decelerations with normal variability in a 20-minute period indicate cord compression or fetal head compression, not a reactive test.
Correct Answer is C
Explanation
Maintain a dark and quiet environment.This intervention helps to reduce sensory stimulation and prevent seizures in a client with eclampsia.
Choice A is wrong becausemonitoring fetal heart rate and uterine activity continuouslyis not a priority intervention for a client with eclampsia.The priority is to prevent seizures and control blood pressure.
Choice B is wrong becauseadministering oxytocin to augment laboris contraindicated in a client with eclampsia.Oxytocin can increase blood pressure and cause uterine hyperstimulation, which can worsen the condition and endanger the mother and the fetus.
Choice D is wrong becauseencouraging oral fluids and a high-protein dietis not appropriate for a client with eclampsia.
The client should be kept NPO to prevent aspiration in case of a seizure.A high-protein diet can increase the risk of renal failure and hepatic dysfunction.
Choice E is wrong becauseassessing for signs of placental abruptionis not a specific intervention for a client with eclampsia.Placental abruption can occur as a complication of eclampsia, but it is not the main focus of care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today