Which of the following actions should a nurse plan to take for a client who is 1 hr postpartum and has preeclampsia without severe features?
Administer an IV bolus of lactated Ringer’s.
Obtain a prescription for misoprostol.
Assess blood pressure twice daily.
Assess for edema.
The Correct Answer is D
Choice A reason: Administering an IV bolus of lactated Ringer’s is not indicated for preeclampsia without severe features, as fluid overload can exacerbate hypertension or pulmonary edema. P ओपेक्शिया involves endothelial dysfunction, and excessive fluids may worsen vascular leakage. Blood pressure and symptom monitoring are prioritized over fluid administration in non-severe cases.
Choice B reason: Misoprostol is used for labor induction or postpartum hemorrhage, not preeclampsia management. Preeclampsia requires blood pressure control and seizure prophylaxis, not cervical ripening agents. Misoprostol’s prostaglandin effects are irrelevant to preeclampsia’s pathophysiology, which involves vasoconstriction and endothelial damage, making this medication inappropriate for the condition’s treatment.
Choice C reason: Assessing blood pressure twice daily is insufficient for preeclampsia, even without severe features, as it requires frequent monitoring (every 4-6 hours) to detect progression to severe hypertension. Preeclampsia can rapidly worsen due to vascular instability, and infrequent checks risk missing critical changes, compromising maternal and fetal safety.
Choice D reason: Assessing for edema is essential in preeclampsia, as it reflects vascular leakage from endothelial dysfunction. Edema, especially in the face or hands, signals worsening disease, necessitating closer monitoring or intervention. This assessment tracks fluid retention, a key pathophysiological feature of preeclampsia, aiding in early detection of progression to severe features.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bladder distention indicates an adverse effect of epidural analgesia, as nerve blockade impairs bladder sensation, leading to retention. This is not a sign of effective pain relief but a complication requiring monitoring or catheterization to prevent urinary tract infections or bladder overdistension, per epidural side effect management.
Choice B reason: Reporting slight pressure with contractions indicates effective epidural analgesia, as it reduces pain while preserving some sensation, allowing awareness of labor progress. This reflects targeted nerve blockade, alleviating visceral pain via opioid and anesthetic action, aligning with the goal of balanced labor analgesia without complete sensory loss.
Choice C reason: Inability to move legs or feet suggests excessive epidural blockade, a complication rather than effective analgesia. Optimal epidurals provide pain relief with minimal motor impairment, allowing mobility. Complete paralysis risks prolonged recovery or injury, not reflecting the therapeutic goal of labor pain management, per anesthesia protocols.
Choice D reason: A 20 mm Hg systolic blood pressure decrease indicates hypotension, an adverse effect of epidural analgesia due to sympathetic blockade. This risks reduced placental perfusion, not effective pain relief. It requires intervention like fluids, contrary to the goal of stable analgesia with minimal maternal or fetal impact.
Correct Answer is D
Explanation
Choice A reason: Early decelerations of the FHR result from head compression during contractions, a benign response reflecting vagal stimulation. They mirror contraction patterns and do not indicate fetal distress. Epidural analgesia may reduce maternal blood pressure, but early decelerations are unrelated to hypoxia, requiring no immediate reporting in this context.
Choice B reason: FHR accelerations of 15 beats/min for 15 seconds indicate fetal well-being, reflecting a responsive autonomic nervous system. They occur with fetal movement or stimulation and are not concerning. Epidural analgesia does not typically cause accelerations, and these findings do not warrant reporting, as they signify normal fetal oxygenation and neurological function.
Choice C reason: An FHR of 150/min is within the normal range (110-160/min) and does not indicate distress. Epidural analgesia may cause maternal hypotension, affecting placental perfusion, but a stable FHR within normal limits reflects adequate fetal oxygenation. This finding does not require immediate reporting, as it aligns with normal fetal physiology.
Choice D reason: Prolonged absent FHR variability suggests fetal compromise, as variability reflects autonomic nervous system function and oxygenation. Epidural analgesia can cause maternal hypotension, reducing placental perfusion and leading to hypoxia, which diminishes variability. This critical finding requires immediate reporting to address potential fetal distress and prevent adverse outcomes like acidosis.
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