Nursing interventions and Management

Total Questions : 5

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Question 1:

A nurse is caring for a client with gestational hypertension who is receiving magnesium sulfate.

What is the main purpose of administering this medication?

Explanation

The correct answer is choice B. To prevent seizures.Magnesium sulfate is a medication that is used to prevent seizures in women with gestational hypertension or preeclampsia.

Seizures can be life-threatening for both the mother and the baby.Magnesium sulfate also has a mild antihypertensive effect, but it is not the main purpose of administering this medication.

Choice A is wrong because magnesium sulfate does not lower blood pressure significantly.Other antihypertensive drugs, such as hydralazine, are used to control blood pressure in women with gestational hypertension or preeclampsia.

Choice C is wrong because magnesium sulfate does not induce labor.It may actually delay labor by relaxing the uterine muscles.Other medications, such as oxytocin, are used to induce labor when needed.

Choice D is wrong because magnesium sulfate does not increase urine output.It may actually decrease urine output by causing fluid retention and renal impairment.Urine output should be monitored closely in women receiving magnesium sulfate to detect signs of toxicity.


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Question 2:

A client with severe preeclampsia is admitted to the hospital.

Which of the following signs would indicate that she is at risk for developing eclampsia?

Explanation

The correct answer is choice A. Headache and blurred vision.These are signs ofcerebral edemaor swelling of the brain, which can lead toeclampsia, a life-threatening complication of preeclampsia that causes seizures.

Choice B is wrong because nausea and vomiting are common symptoms of pregnancy and do not indicate a risk for eclampsia.

Choice C is wrong because edema and weight gain are also common in pregnancy and may be due to fluid retention or increased blood volume.

They are not specific signs of preeclampsia or eclampsia.

Choice D is wrong because proteinuria and oliguria are signs ofkidney damagedue to preeclampsia, but they do not directly increase the risk of eclampsia.However, they may indicate severe preeclampsia that requires close monitoring and treatment.

Normal ranges for blood pressure, proteinuria, platelet count, and liver enzymes are as follows:

• Blood pressure: less than 140/90 mm Hg

• Proteinuria: less than 300 mg per 24 hours

• Platelet count: 150,000 to 400,000 per microliter

• Liver enzymes: AST less than 40 U/L, ALT less than 45 U/L


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Question 3:

A nurse is monitoring a client with gestational hypertension for signs of fluid retention and edema.

Which of the following assessments would be most helpful?

Explanation

The correct answer is choice C. Weighing the client daily at the same time.This is because weight gain and edema are common signs of fluid retention and preeclampsia, a serious complication of gestational hypertension.Weighing the client daily at the same time can help monitor the fluid status and detect any sudden changes that may indicate worsening preeclampsia.

Choice A is wrong because measuring abdominal girth daily is not a reliable indicator of fluid retention or edema, as it can also be affected by fetal growth, uterine size, and maternal fat distribution.

Choice B is wrong because checking for pitting edema in the lower extremities is not a specific sign of preeclampsia, as it can also occur in normal pregnancies due to increased blood volume and venous pressure.

Choice D is wrong because auscultating lung sounds for crackles is not a helpful assessment for fluid retention and edema, as it is a late sign of pulmonary edema, which is a rare but life-threatening complication of severe preeclampsia.


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Question 4:

A nurse is teaching a client with gestational hypertension about dietary modifications.

Which of the following instructions would be appropriate?

Explanation

The correct answer is choice C. Avoid foods high in sodium such as canned soups and processed meats.This is because sodium can increase blood pressure and fluid retention, which are complications of gestational hypertension.

Choice A is wrong because increasing calcium intake does not prevent bone loss in gestational hypertension.Calcium supplementation may be beneficial for preventing preeclampsia, which is a more severe form of gestational hypertension.

Choice B is wrong because limiting fluid intake to 1 liter per day can cause dehydration and electrolyte imbalance, which can harm both the mother and the fetus.Fluid intake should be adequate to maintain hydration and urine output.

Choice D is wrong because eating foods rich in iron is not related to gestational hypertension.

Iron intake may be important for preventing anemia, which can occur in pregnancy due to increased blood volume and fetal demands.


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Question 5:

A nurse is preparing a client with gestational hypertension for delivery.

Which of the following factors would indicate that the client is ready for delivery?

Explanation

The correct answer is choice D. All of the above.

All of these factors would indicate that the client is ready for delivery because they pose a risk to the mother or the fetus or both.

Choice A is wrong because blood pressure that is uncontrollable despite medication can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome.

Choice B is wrong because fetal distress detected by nonstress test or biophysical profile can indicate hypoxia, acidosis, or cord compression.

Choice C is wrong because term is reached (37 weeks or more) does not necessarily mean that the client is ready for delivery.Other factors such as cervical dilation, effacement, and station also need to be considered.

Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and 80/60 mmHg or lower for diastolic.Normal ranges for nonstress test are two or more fetal heart rate accelerations of at least 15 beats per minute above baseline lasting at least 15 seconds in a 20-minute period.Normal ranges for biophysical profile are a score of 8 to 10 out of 10 based on five parameters: fetal breathing movements, fetal movements, fetal tone, amniotic fluid volume, and nonstress test.


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