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A client at 37 weeks of gestation with severe gestational hypertension is being admitted by a nurse. Which of the following actions should the nurse NOT expect to implement?
- A. Administer magnesium sulfate IV.
- B. Provide a dark, quiet environment.
- C. Assess respiratory status every 4 hours.
- D. Ensure that calcium gluconate is readily available.
Correct Answer: C
Rationale: Assessing respiratory status every 4 hours is not a priority for a client with severe gestational hypertension. In this scenario, the focus should be on monitoring blood pressure, assessing for signs of preeclampsia, administering medications like magnesium sulfate for seizure prophylaxis, and ensuring that calcium gluconate is readily available in case of magnesium toxicity. Respiratory status assessment is important in other conditions but is not directly related to managing severe gestational hypertension.
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A client who is 4 hours postpartum following a vaginal delivery is being assessed by a nurse. Which of the following findings should the nurse identify as the priority?
- A. Saturated perineal pad in 30 minutes
- B. Deep tendon reflexes 4+
- C. Fundus at the level of the umbilicus
- D. Approximated edges of episiotomy
Correct Answer: A
Rationale: In a client who is 4 hours postpartum, a saturated perineal pad within 30 minutes is a priority finding as it may indicate excessive postpartum bleeding (hemorrhage), which requires immediate intervention to prevent further complications such as hypovolemic shock. Deep tendon reflexes being 4+ is within normal limits postpartum. The fundus at the level of the umbilicus is an expected finding at this time frame, indicating proper involution of the uterus. Approximated edges of an episiotomy suggest proper healing.
A healthcare provider is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?
- A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
- B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
- C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
- D. A client who has a diagnosis of preeclampsia reports epigastric pain and an unresolved headache
Correct Answer: D
Rationale: The correct answer is a client who has a diagnosis of preeclampsia reporting epigastric pain and an unresolved headache. These symptoms indicate severe preeclampsia, which requires immediate medical attention due to the potential risks of complications such as HELLP syndrome or eclampsia. The other options describe concerning situations but do not represent immediate life-threatening conditions like those seen in severe preeclampsia.
During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
- A. Increased urine output
- B. Vaginal discharge
- C. Elevated blood pressure
- D. Joint pain
Correct Answer: C
Rationale: Preeclampsia is characterized by elevated blood pressure, proteinuria, and sometimes edema. Hypertension is a key sign of preeclampsia, and if present, further evaluation and monitoring are necessary to prevent complications for both the mother and the fetus.
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
- A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
- B. Observe an area of redness on the breast of a client who is 1 day postpartum.
- C. Monitor vital signs during admission of a client who has gestational hypertension.
- D. Change the perineal pad of a client who just transferred from labor and delivery.
Correct Answer: A
Rationale: Delegating the task of providing a sitz bath to a client with a fourth-degree laceration and who is 2 days postpartum to the assistive personnel (AP) is appropriate. This task involves assisting the client with personal hygiene and comfort measures that can be safely performed by the AP under the supervision and direction of the nurse. Tasks like observing redness on the breast, monitoring vital signs during admission for gestational hypertension, and changing perineal pads may require a higher level of assessment and nursing judgment, making them more appropriate for the nurse to perform.
A client at 22 weeks of gestation with uncontrolled gestational diabetes mellitus may require medication. Which of the following medications would the provider likely prescribe?
- A. Acarbose
- B. Repaglinide
- C. Glyburide
- D. Glipizide
Correct Answer: C
Rationale: Glyburide is commonly prescribed for gestational diabetes mellitus when diet and exercise are insufficient to control blood sugar levels. It is considered safe and effective during pregnancy, making it a suitable choice for managing diabetes in pregnant individuals. Acarbose, Repaglinide, and Glipizide are not typically recommended for use in pregnancy due to potential risks to the fetus.