Diagnostic Criteria and Investigations
Diagnostic Criteria and Investigations ( 16 Questions)
(select all that apply) A nurse is planning care for a client with eclampsia who is scheduled for delivery as soon as possible.
Which of the following interventions should the nurse include in the plan? (Select all that apply.)
Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension. The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption.
Administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Assessing for signs of placental abruption is not enough. The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Answer is A and C. Eclampsia is a life-threatening complication of pregnancy that causes seizures due to severe hypertension. The nurse should monitor the fetal heart rate and uterine activity continuously to assess for signs of fetal distress or placental abruption. The nurse should also maintain a dark and quiet environment to reduce stimuli that might trigger seizures.
Statement B is wrong because administering oxytocin to augment labor can increase the risk of uterine rupture and placental abruption in a patient with eclampsia.
Statement D is wrong because encouraging oral fluids and a high-protein diet can worsen the fluid retention and renal impairment in a patient with eclampsia.
Statement E is wrong because assessing for signs of placental abruption is not enough. The nurse should also monitor the vital signs, urine output, neurological status, and laboratory values of the patient with eclampsia.
Normal ranges for blood pressure are less than 120/80 mmHg for non-pregnant adults and less than 140/90 mmHg for pregnant women. Normal ranges for protein in urine are less than 150 mg/day for non-pregnant adults and less than 300 mg/day for pregnant women.