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The nurse is continuing to assist with the care of the client.

The nurse is assisting with Initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Administer betamethasone.

Maintain bed rest.

Obtain a 24-hr urine specimen.

Monitor intake and output every hour.

Assist RN with performing a vaginal examination every 12 hr.

Provide a low-stimulation environment.

Give antihypertensive medication.

Answer and Explanation

Correct Answer : A,B,C,D,F,G

Initiating the plan of care for a 31-week pregnant client with severe hypertension, proteinuria, thrombocytopenia, and elevated liver enzymes indicates a severe hypertensive disorder of pregnancy consistent with Preeclampsia with severe features. This condition places both maternal and fetal life at risk due to vasospasm, endothelial injury, and impaired placental perfusion. Priority care focuses on preventing progression to eclampsia, managing severe hypertension, monitoring organ function, and preparing for potential preterm delivery. Interventions aim to stabilize maternal status while optimizing fetal outcomes.

Rationale:
A. Administering betamethasone is appropriate because it accelerates fetal lung maturity in anticipation of possible preterm delivery. In severe preeclampsia, early delivery may be necessary to protect maternal and fetal health. Corticosteroids reduce neonatal respiratory distress syndrome by promoting surfactant production in the fetal lungs.

B. Maintaining bed rest helps reduce blood pressure and improves uteroplacental perfusion by decreasing physical and metabolic stress. Although strict bed rest is no longer universally recommended for all pregnancies, in severe preeclampsia it may help minimize stimulation and reduce risk of seizure activity. It also supports monitoring and stabilization in a controlled environment.

C. Obtaining a 24-hour urine specimen is important to quantify protein excretion and evaluate severity of renal involvement. Significant proteinuria is a hallmark of preeclampsia and helps guide diagnosis and ongoing management. It also provides baseline data for monitoring disease progression and response to treatment.

D. Monitoring intake and output hourly is essential due to risk of renal impairment and fluid shifts associated with preeclampsia. Reduced urine output may indicate worsening kidney perfusion or progression to end-organ dysfunction. Strict fluid monitoring also helps prevent fluid overload, which can lead to pulmonary edema.

E. Performing routine vaginal examinations every 12 hours is not indicated and may increase risk of infection or iatrogenic complications. In preeclampsia, unnecessary cervical manipulation should be avoided unless there is a clear obstetric indication for labor assessment. This intervention does not contribute to stabilization of maternal condition.

F. Providing a low-stimulation environment is critical to reduce the risk of seizure activity in severe preeclampsia. Minimizing noise, light, and stress helps decrease cerebral irritability and blood pressure fluctuations. This intervention is a key non-pharmacologic strategy to prevent progression to eclampsia.

G. Administering antihypertensive medication is necessary to control severe blood pressure elevations and reduce risk of stroke or placental abruption. Severe hypertension (≥160/110 mmHg) requires prompt pharmacologic management. Controlling blood pressure helps stabilize maternal condition and improve uteroplacental circulation.

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Correct Answer is D

Explanation

Age-related macular degeneration is a progressive retinal disorder affecting the macula, the portion of the retina responsible for central detailed vision. Degeneration of macular photoreceptor cells leads to impaired visual acuity, difficulty reading, and reduced ability to recognize faces or perform fine visual tasks. Peripheral vision is typically preserved, but central vision progressively deteriorates. Nurses caring for clients with this condition should recognize characteristic visual changes associated with retinal damage.

Rationale:
A. Nystagmus is an involuntary rhythmic eye movement commonly associated with neurologic disorders, vestibular dysfunction, or congenital visual impairment. It is not a characteristic finding of macular degeneration because the disorder primarily affects retinal central vision rather than ocular motor control. Therefore, this finding would not be expected.

B. Astigmatism is a refractive error caused by irregular curvature of the cornea or lens, leading to blurred vision at multiple distances. It is unrelated to retinal degeneration and does not result from macular damage. Macular degeneration affects the retina itself rather than the refractive structures of the eye.

C. Sharp eye pain is not typically associated with macular degeneration. The condition is generally painless because retinal degeneration does not stimulate pain receptors. Sudden or severe ocular pain would suggest another disorder such as glaucoma, corneal injury, or acute inflammation rather than Macular degeneration.

D. Loss of central vision is the hallmark finding of macular degeneration due to progressive deterioration of the macula. Clients commonly report blurred or distorted central vision, difficulty reading, or dark spots in the center of their visual field. Peripheral vision is often maintained despite significant central visual impairment.

A. Bright red vaginal bleeding B. Rigid abdomen C. Increased fetal movement D. Persistent uterine contractions

Correct Answer is A

Explanation

Placenta previa is a pregnancy complication in which the placenta implants low in the uterus and partially or completely covers the cervical os. This abnormal positioning can lead to painless vaginal bleeding, especially in the second or third trimester as the cervix begins to efface and dilate. The condition poses a risk for maternal hemorrhage and fetal compromise due to disruption of placental attachment. Clinical management focuses on bleeding assessment, fetal monitoring, and preventing further cervical irritation.

Rationale:
A. Bright red vaginal bleeding is the hallmark finding of Placenta previa. The bleeding is typically painless and results from placental separation as the lower uterine segment stretches. The bright red color indicates fresh arterial bleeding, which is a key distinguishing feature from other obstetric emergencies.

B. A rigid abdomen is more commonly associated with placental abruption rather than placenta previa. In abruption, the placenta detaches prematurely, causing uterine tenderness and a board-like abdomen. Placenta previa typically presents without abdominal pain or uterine rigidity.

C. Increased fetal movement is not a typical finding in placenta previa and does not indicate pathology specific to this condition. Fetal movement patterns may vary but are not diagnostic or expected as a clinical sign of placenta previa. In severe cases of bleeding, fetal activity may actually decrease due to hypoxia.

D. Persistent uterine contractions are not characteristic of placenta previa. The uterus is usually soft and non-tender, and contractions are not a defining feature. If contractions occur, they may suggest labor or another obstetric complication rather than placenta previa.

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The nurse is continuing to assist with the care of the client. The nurse is assisting with Initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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The nurse is assisting with Initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.