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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Washing the circumcision site with soap and water 24 hours post-procedure risks disrupting the healing process. The plastic bell device remains in place for 5-7 days, and cleaning should avoid soap to prevent irritation. Healing relies on a dry environment to promote tissue repair and prevent infection.
Choice B reason: Removing the plastic bell 2 hours after circumcision is incorrect, as it is designed to remain in place for 5-7 days until the foreskin necroses and detaches. Premature removal risks bleeding and incomplete circumcision. The device ensures controlled tissue compression, supporting hemostasis and proper healing through localized necrosis.
Choice C reason: Monitoring for bleeding every 15 minutes for the first hour is critical, as circumcision carries a risk of hemorrhage due to penile vascularity. Frequent checks ensure early detection of complications, as neonatal coagulation is immature. This intervention supports hemostasis monitoring, aligning with post-surgical care to prevent significant blood loss.
Choice D reason: Removing yellow drainage on day two is inappropriate, as it may represent normal fibrinous exudate, a part of healing. Disturbing it risks infection or delayed tissue repair. The plastic bell promotes necrosis and healing, and exudate is expected unless accompanied by pus or odor, indicating infection.
Correct Answer is A
Explanation
Choice A reason: Fentanyl citrate is appropriate for severe labor pain, as it provides rapid-onset analgesia via IV administration, crossing the blood-brain barrier to block pain signals. Its short half-life minimizes fetal respiratory depression, making it safe for labor. Fentanyl targets opioid receptors, offering effective pain relief, per obstetric analgesia protocols.
Choice B reason: Naloxone hydrochloride is an opioid antagonist used to reverse opioid overdose, not to manage labor pain. It blocks opioid receptors, reversing analgesia, which would exacerbate pain. In labor, naloxone is reserved for neonatal respiratory depression from maternal opioids, not maternal pain relief, per pharmacological principles.
Choice C reason: Naproxen, a nonsteroidal anti-inflammatory drug, is unsuitable for labor pain, as it primarily reduces inflammation and mild pain via prostaglandin inhibition. Labor pain requires rapid, potent analgesia like fentanyl. Naproxen’s slow onset and limited efficacy for visceral pain make it inappropriate for active labor, per pain management guidelines.
Choice D reason: Hydrocodone, an oral opioid, is not used in active labor due to its slow onset and prolonged duration, risking fetal respiratory depression. IV fentanyl provides faster, controlled analgesia suitable for labor’s acute pain. Hydrocodone’s pharmacokinetics are better suited for postpartum or chronic pain, not intrapartum use.
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