A nurse is counseling a preeclamptic client about her diet. Which should the nurse encourage the woman to do?

Correct Answer: C

Rationale: In counseling a preeclamptic client about her diet, it is crucial to encourage her to eat a well-balanced diet, which is the correct answer (Option C). This recommendation is based on the fact that a balanced diet provides essential nutrients necessary for both the mother and the developing fetus. Preeclampsia is a condition characterized by high blood pressure and protein in the urine during pregnancy, and proper nutrition plays a key role in managing this condition. Option A, restricting sodium intake, is not the best choice because while excessive sodium intake can contribute to fluid retention and high blood pressure, complete restriction is not recommended during pregnancy as some sodium is necessary for normal bodily functions. Option B, increasing intake of fluids, is important for overall health, but in the context of preeclampsia, excessive fluid intake may exacerbate fluid retention and swelling. Option D, avoiding simple sugars, is generally a good dietary practice, but it is not the priority when counseling a preeclamptic client. The focus should be on ensuring a well-balanced diet to provide adequate nutrients for both the mother and the baby. In an educational context, it is important for nurses and healthcare providers to have a solid understanding of nutrition recommendations for pregnant women, especially those with conditions like preeclampsia. Providing evidence-based dietary advice can help improve maternal and fetal outcomes and support overall health during pregnancy.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Grand mal seizure. The gravid client's presentation with 4+ proteinuria and 4+ reflexes indicates a severe condition known as preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, often the kidneys and liver. Preeclampsia puts the client at high risk for eclampsia, a more severe condition marked by seizures. Therefore, close monitoring for the development of seizures is crucial in this situation to prevent serious complications for both the mother and the fetus. Option B) High platelet count is incorrect because in preeclampsia, platelet count tends to decrease, leading to a risk of bleeding disorders rather than high platelet counts. Option C) Explosive diarrhea is not directly associated with the signs and symptoms of preeclampsia. While gastrointestinal issues can occur in some cases, they are not a primary concern in the context of a client presenting with significant proteinuria and reflex changes. Option D) Fractured pelvis is unrelated to the client's condition of preeclampsia. This option introduces a physical injury concern, which is not relevant to the client's current medical condition. Educationally, understanding the signs and symptoms of preeclampsia and its potential complications is critical for healthcare providers caring for pregnant clients. Timely recognition and appropriate management of conditions like preeclampsia can significantly impact maternal and fetal outcomes. Close monitoring and prompt intervention are essential in the care of pregnant clients at risk for developing complications like seizures in the context of preeclampsia.

Correct Answer: D

Rationale: In the scenario presented, the correct answer is D) Epigastric pain. Severe preeclampsia with HELLP syndrome is a serious condition characterized by high blood pressure, protein in the urine, and liver abnormalities. Epigastric pain is a common symptom of HELLP syndrome and indicates liver distention. Assessing for epigastric pain is crucial as it can signify worsening of the condition and potential liver rupture, which is a life-threatening complication. Option A) Low serum creatinine is incorrect because in HELLP syndrome, renal function is usually impaired, leading to elevated serum creatinine levels. Option B) High serum protein is incorrect because while protein in the urine is a hallmark of preeclampsia, it is not specific to HELLP syndrome. Option C) Bloody stools is incorrect because it is not a typical sign/symptom associated with severe preeclampsia with HELLP syndrome. Educationally, understanding the signs and symptoms of maternal diseases like preeclampsia and HELLP syndrome is crucial for nurses and healthcare providers working in obstetrics. Prompt recognition and appropriate management of these conditions are vital to prevent maternal and fetal complications. Knowledge of these conditions helps in providing safe and effective care to pregnant women, ensuring better outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Headache and decreased output. This symptom combination could indicate preeclampsia, a serious condition characterized by high blood pressure and organ damage. Teaching the client to watch for these signs is crucial for early detection and intervention. Option B) Puffy feet is a common occurrence in pregnancy due to fluid retention and is not necessarily a cause for immediate concern unless accompanied by other symptoms like high blood pressure. Option C) Hemorrhoids and vaginal discharge are common discomforts in pregnancy but are not typically indicators of a serious complication in the second half of pregnancy that would require immediate attention. Option D) Backache is a common complaint during pregnancy and is usually related to postural changes and the growing uterus pressing on nerves and muscles. While discomforting, it is not typically a sign of a complication that requires immediate medical attention. Educationally, this question highlights the importance of patient education in recognizing warning signs for potential complications during pregnancy. Teaching pregnant clients to be aware of specific symptoms and when to seek medical advice can help in the early detection and management of maternal diseases, ultimately improving outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In caring for an infant born with myelomeningocele, the highest priority nursing intervention is to protect the sac from injury (Option A). This is crucial to prevent infection and further damage to the exposed spinal cord. By covering the sac with a sterile, moist, non-adherent dressing, the risk of infection is minimized, and the infant is protected from trauma. Option B, preparing the parents for the child's paralysis, is important but not the highest priority at this moment. The immediate focus should be on protecting the sac to prevent complications. Option C, preparing for sac closure at around 2 years of age, is a valid intervention but is not the most urgent in the immediate postnatal period. Option D, assessing for cyanosis, is not directly related to the immediate care needed for a newborn with myelomeningocele. Educationally, understanding the critical nature of protecting the sac in infants with myelomeningocele highlights the importance of early intervention to prevent complications. Nurses play a vital role in educating parents and providing hands-on care to ensure the best outcomes for these vulnerable infants. By prioritizing sac protection, nurses can contribute significantly to the infant's well-being and long-term health.