The nurse is reviewing the client's laboratory results.
The client is reporting a severe headache, nausea, and right-sided upper abdominal pain.
The nurse notes deep tendon reflexes are 4+. What is the priority nursing intervention?
Administering acetaminophen for the headache.
Providing metoclopramide for the nausea.
Monitoring for seizure activity.
Preparing the client for a stat C-section.
Encouraging the client to ambulate to the bathroom.
The Correct Answer is C
Choice A rationale
Administering acetaminophen, a weak analgesic, addresses only a symptom and does not treat the underlying pathology of preeclampsia. The client's elevated deep tendon reflexes (4+, normal is 2+) and other symptoms strongly suggest central nervous system irritability and impending seizures, which is the priority concern. Focusing on symptom management delays critical interventions.
Choice B rationale
Metoclopramide is an antiemetic that treats nausea by blocking dopamine receptors in the chemoreceptor trigger zone. While nausea is a symptom, it is not the most critical one in this scenario. The priority is to address the severe central nervous system irritability, which poses a greater immediate threat to the client's and fetus's safety.
Choice C rationale
The client's deep tendon reflexes of 4+, a sign of hyperreflexia, indicate a heightened state of central nervous system excitability. This finding, along with the headache, nausea, and upper abdominal pain, is highly suggestive of severe preeclampsia and impending eclampsia. The priority is to anticipate and prevent a seizure, which is a life-threatening complication.
Choice D rationale
A stat C-section is a definitive treatment for severe preeclampsia, but it is not the immediate priority nursing intervention. The priority is to stabilize the client and prevent a seizure while preparing for delivery. A C-section is a medical decision made by the physician, not a primary nursing intervention.
Choice E rationale
Encouraging ambulation is contraindicated in a client with signs of severe preeclampsia. Physical activity can exacerbate hypertension and increase the risk of a seizure due to increased physiological stress. Bed rest is typically recommended to decrease blood pressure and reduce the risk of further complications in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Morphine is an opioid analgesic, not a primary antihypertensive, although it can have a vasodilatory effect. Magnesium sulfate is a central nervous system depressant and vasodilator used to prevent seizures in preeclampsia, but it is the second substance listed and the question asks for the order.
Choice B rationale
Magnesium sulfate is the second substance listed, and the question asks for the substance to decrease blood pressure first. While magnesium sulfate is a vasodilator, its primary use in this context is seizure prophylaxis. Hydralazine is an antihypertensive, but it is listed as the second substance for seizure prevention.
Choice C rationale
Hydralazine is an antihypertensive and would decrease blood pressure, but lorazepam is a benzodiazepine used to treat active seizures, not prevent them. Magnesium sulfate is the agent of choice for seizure prophylaxis in preeclampsia.
Choice D rationale
Hydralazine is a direct-acting vasodilator that primarily relaxes arterial smooth muscle, leading to a decrease in peripheral vascular resistance and, consequently, a reduction in blood pressure. Magnesium sulfate is a central nervous system depressant that decreases neuromuscular excitability, thereby preventing seizures in conditions like preeclampsia.
Correct Answer is B
Explanation
Choice A rationale
A blood pressure of 130/85 mm Hg is within a generally acceptable range for a pregnant woman in labor and does not typically indicate an immediate emergency. While elevated, it is not a classic sign of fetal distress and does not take priority over direct indicators of the fetal condition. The normal range is less than 140/90 mmHg.
Choice B rationale
A fetal heart rate of 100 to 110 beats/minute is considered fetal bradycardia, which is a significant and concerning sign of fetal distress. The normal fetal heart rate is between 110 and 160 beats/minute. When coupled with meconium-stained amniotic fluid, this finding strongly suggests fetal hypoxia and requires immediate medical attention and intervention.
Choice C rationale
Contractions every 2 to 3 minutes are a normal pattern for active labor. This frequency indicates that the uterine muscles are contracting effectively to dilate the cervix. This finding is expected during this stage of labor and does not represent an urgent risk to the fetus or mother.
Choice D rationale
A cervical dilation of 6 cm is a normal finding for the active phase of labor. It indicates a progression of labor and is not a sign of a complication. This finding, while important for labor progress, does not indicate an immediate fetal or maternal emergency.
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