Perfusion

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing interventions should a nurse perform to institute and maintain seizure precautions in this client? a. Provide a well-lit room b. Keep head of bed slightly elevated c. Place the client in a supine position d. Keep the suction equipment readily available

D RATIONALE: The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine the effectiveness of therapy? a. Assess deep tendon reflexes b. Monitor intake and output c. Assess client's mucous membrane d. Assess client's skin turgor

A RATIONALE: If the client is receiving magnesium sulfate to suppress or control seizures, assess deep tendon reflexes to determine the effectiveness of therapy. Common sites utilized to assess deep tendon reflexes are the biceps reflex, triceps reflex, patellar reflex, Achilles reflex, and plantar reflex. ASsessing the mucous membranes for dryness and skin turgor for dehydration are the required interventions when caring for a client with hypermesis gravidarum. Monitoring intake and output will not help to determine the effectivness of therapy.

The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply. a. Blood pressure higher than 160/110 b. Epigastric pain c. Oliguria d. Upper right quadrant pain e. Hyperbilirubinemia

B, D, E RATIONALE: The signs and symptoms of HELLP syndrome are nausea, malaise, epigastric pain, upper right quadrant pain, demonstrable edema, and hyperbilirubinemia. Blood pressure higher than 160/110 and oliguria are the symptoms of severe preeclampsia rather than HELLP syndrome.

A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia? a. Muscle rigidity is followed by facial twitching. b. Respirations are rapid during the seizure. c. Coma occurs after seizure. d. Respiration fails after the seizure.

C RATIONALE: The nurse should know that coma usually follows an eclamptic seizure. Muscle rigidity occurs after facial twitching. Respirations do not become rapid during the seizure; they cease. Coma usually follows the seizure activity, with respiration resuming.

A nurse is performing CPR on a patient who is in cardiac arrest. What action would the be nurse perform second? a. Check the victim for a response b. Begin CPR with the CAB sequence c. Get an automated external defibrillator (AED) or defibrillator. d. Activate the emergency response system.

d. Activate the emergency response system.

A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which description of dependent edema is most accurate? a. Dependent edema leaves a small depression or pit after finger pressure is applied to a swollen area. b. Dependent edema occurs only in clients on bed rest. c. Dependent edema can be measured when pressure is applied. d. Dependent edema may be seen in the sacral area if the client is on bed rest.

D RATIONALE: The nurse should know that dependent edema may be seen in the sacral area if the client is on bed rest. Pitting edema leaves a small depression or pit after finger pressure is applied to a swollen area and can be measured. Dependent edema may occur in clients who are both ambulatory and on bed rest.