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The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
- A. “Plan for hospitalization when nearing 36 weeks’ gestation.”
- B. “Weigh daily and inform the HCP of a sudden increase in weight.”
- C. “Home care will be consulted to take your blood pressure (BP) daily.”
- D. “Perform stretching and range-of-motion exercises twice daily.”
- E. “Rest as much as possible, especially in the lateral recumbent position.”
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.
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The nurse is counseling the client who has SLE. The client tells the nurse that she plans to become pregnant in the next year. Which response by the nurse is correct?
- A. “It is best to plan for your pregnancy when you have been in remission for 6 months.”
- B. “Having systemic lupus erythematosus will not impact your pregnancy in any way.”
- C. “Your chances of having an infant with congenital malformations are increased with SLE.”
- D. “You will need to be scheduled for a cesarean delivery to prevent disease transmission.”
Correct Answer: A
Rationale: Planning for pregnancy with SLE when in remission for 6 months is correct. Pregnancy planned during periods of inactive or stable disease often results in giving birth to a healthy full-term baby without increased risks of pregnancy complications. Exacerbations of SLE can occur during pregnancy and impact pregnancy outcomes. There is no risk of congenital malformations associated with maternal SLE. However, the risk for spontaneous abortion, preterm labor and birth, and neonatal death is increased. SLE is not a transmissible disease, and there is no reason for a cesarean delivery.
The nurse considers prenatal teaching successful when the class correctly identifies which of the following as a danger sign of pregnancy?
- A. Headache and swelling of the face and fingers
- B. Constipation and flatulence on a regular basis
- C. Lower extremity muscle cramping and varicosities
- D. Large amounts of odorless, colorless vaginal secretions
Correct Answer: A
Rationale: Headache and swelling of the face and fingers may indicate preeclampsia, a serious condition requiring immediate attention.
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
Which expected outcome should the nurse include based on the client's eating habits?
- A. The client will eat three balanced meals and two snacks daily while pregnant.
- B. The client will gain a total of 50 pounds during the pregnancy.
- C. The client will take two prenatal vitamins daily.
- D. The client will report eating about 2,000 calories per day.
Correct Answer: A
Rationale: Eating three balanced meals and two snacks daily addresses the client's poor eating habits and supports nutritional needs.
The husband of the postpartum client diagnosed with moderate postpartum depression (PPD) asks the nurse about the treatments his wife will require. The nurse’s response should be based on knowing that which treatments are included in the initial collaborative plan of care? Select all that apply.
- A. Antidepressant medication
- B. Individual or group psychotherapy
- C. Removal of the infant from the home
- D. Sedative-hypnotic agents
- E. Electroconvulsive therapy (ECT)
Correct Answer: A,B
Rationale: SSRIs are first-line agents for treating moderate PPD. Individual or group psychotherapy is a treatment for moderate PPD. If the client is displaying rejection of or aggression toward the infant, she should not be left alone with the infant, but the infant does not need to be removed from the home. Hypnotic agents are medications that promote sleep, but they are not to be used during the postpartum period. If sleep deprivation is occurring, a TCA may be prescribed. ECT would not be used in the initial treatment of moderate PPD. If puerperal psychosis develops, ECT is a treatment option.