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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Perform a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Administer betamethasone.

Monitor intake and output hourly.

Give antihypertensive medication.

Provide a low-stimulation environment

Maintain bed rest.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Ensure that the transfusion is completed within 6 hr: Incorrect. Blood transfusions should be completed within 4 hours to reduce the risk of bacterial contamination.

B. Obtain venous access using a 22-gauge needle: Incorrect. A larger gauge (18-20) is preferred to prevent hemolysis and allow for faster administration.

C. Store the unit of blood at room temperature for 1 hr prior to the infusion: Incorrect. Blood should remain refrigerated until it is ready to be transfused, and it should be started within 30 minutes of removal from refrigeration.

D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing: 0.9% sodium chloride is the only compatible solution with blood products to prevent hemolysis.

A. A reddened area measuring 10 mm B. A reddened area measuring 5 mm C. An induration measuring 5 mm D. An induration measuring 10 mm

Correct Answer is D

Explanation

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Nursing Test Bank

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The nurse is continuing to care for the client.

Exhibits

The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.