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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Initiate contact precautions.

Check urinary output.

Decrease lighting in the client's room.

Monitor blood pressure.

Prepare for amniocentesis.

Apply Internal fetal monitor.

Assess DTR.

Encourage bed rest.

Answer and Explanation

Correct Answer : B,C,D,G,H

A. Contact precautions are not indicated based on the assessment findings provided. Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.

B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.

D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.

E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.

F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.

G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.

H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.

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Correct Answer is A

Explanation

A. Wiping the nose instead of blowing it reduces the risk of trauma to the nasal mucosa, which can lead to bleeding, especially in individuals with thrombocytopenia.
B. Removing shoes inside the house is a general hygiene practice and does not specifically address the risk of bleeding associated with thrombocytopenia.
C. Using an enema to manage constipation is unrelated to thrombocytopenia and may not be indicated without further assessment and guidance from healthcare providers.
D. While oral hygiene is important, flossing may increase the risk of gum bleeding in individuals with thrombocytopenia, and its frequency should be discussed with healthcare providers.

A. Blood pressure B. Temperature C. Heart rate D. Oxygen saturation E. Travel history F. Weight G. Sputum characteristics H. Report of cough

Correct Answer is ["B","E","G","F","H"]

Explanation

A. While monitoring blood pressure is essential in the overall assessment of a patient, the given blood pressure readings (112/88 mm Hg) are within the normal range. Hence, further evaluation of blood pressure may not be immediately necessary based on the provided information.
B. A temperature of 38.1°C (100.5°F) indicates fever, which can be a sign of infection or inflammatory process. Further evaluation is warranted to determine the cause of the fever and initiate appropriate treatment.
C. The heart rate of 98/min falls within the normal range for adults (60-100 beats per minute). Although heart rate abnormalities can indicate various conditions, the given heart rate alone may not warrant immediate further evaluation without additional concerning symptoms or clinical context.
D. The oxygen saturation of 98% on room air is within the normal range (>95%).

While assessing oxygen saturation is crucial, the provided value does not indicate immediate concern. Further evaluation may be needed if the patient shows signs of respiratory distress or if there is clinical suspicion of hypoxemia.

E. Recent travel to South Africa raises concerns about potential exposure to infectious diseases endemic to that region. Further evaluation is necessary to assess for travel- related illnesses or infections, such as tuberculosis or other tropical diseases.
F. A significant weight loss of 2.26 kg (5 lb) over the last week is concerning and requires further investigation. Unintentional weight loss can be indicative of various underlying medical conditions, including infections, malignancies, or metabolic disorders.
G. The report of "blood-tinged sputum" suggests hemoptysis, which can be a sign of serious underlying conditions such as pulmonary infections, pulmonary embolism, or malignancy. Further evaluation is necessary to determine the cause and initiate appropriate management.
H. The presence of a persistent cough, especially when associated with other symptoms like fatigue, night sweats, and weight loss, raises concerns for underlying respiratory or systemic conditions. Further assessment is needed to identify the cause of the cough and provide appropriate treatment.

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The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

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A nurse is providing teaching to a client who has thrombocytopenia following chemotherapy. Which of the following statements Indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is ["B","E","G","F","H"]

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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.