The nurse is monitoring a pregnant client with severe preeclampsia. Which finding requires immediate intervention?

Correct Answer: C

Rationale: In the context of severe preeclampsia, the finding that requires immediate intervention is option C, complaints of headache and blurred vision. These symptoms indicate possible progression to eclampsia, a life-threatening condition characterized by seizures. Prompt action is crucial to prevent maternal and fetal complications. Option A, a blood pressure of 140/90 mmHg, although elevated, is not an immediate concern in the setting of severe preeclampsia where blood pressure levels are typically much higher and can lead to organ damage. Option B, urine output of 30 mL/hr, is concerning but not as urgent as symptoms of impending eclampsia. Adequate hydration and monitoring are important, but immediate intervention is needed for neurological symptoms. Option D, a weight gain of 1 pound in one week, while indicating fluid retention, is not as critical as the potential neurological complications associated with eclampsia. Educationally, this question highlights the importance of recognizing critical symptoms in preeclampsia management. Nurses must be vigilant in assessing and responding to signs of worsening conditions to prevent severe outcomes for both the mother and baby. Early identification and intervention can significantly impact the prognosis in cases of severe preeclampsia.

Correct Answer: C

Rationale: In this scenario, the best response to the pregnant client's question about the purpose of an ultrasound at 20 weeks' gestation is option C: To assess fetal anatomy and growth. This option is correct because at 20 weeks, an ultrasound is typically performed to evaluate the baby's anatomical development, confirm the presence of vital organs, assess growth milestones, and identify any potential abnormalities. Option A (To confirm pregnancy viability) is incorrect because viability is usually confirmed earlier in the pregnancy through methods like transvaginal ultrasound or fetal heartbeat detection. Option B (To check for genetic abnormalities) is also incorrect as genetic testing, such as amniocentesis or chorionic villus sampling, is usually done for this purpose, not a routine 20-week ultrasound. Option D (To determine the sex of the baby) is not the primary purpose of a 20-week ultrasound, although it may be possible to determine the baby's sex during this scan if desired by the parents. Educationally, understanding the purpose of various prenatal tests and screenings is crucial for healthcare providers working with pregnant clients. It ensures appropriate information is provided to expectant parents and helps in identifying and addressing any potential issues early in the pregnancy. Providing accurate and detailed explanations to pregnant clients fosters trust, empowers informed decision-making, and promotes positive maternal and fetal outcomes.

Correct Answer: B

Rationale: In the context of pharmacology related to maternal health, understanding the timing of group B streptococcus (GBS) testing is crucial for providing optimal care to pregnant clients. The correct answer is B) Between 35–37 weeks' gestation. This timing is essential because GBS colonization status can change during pregnancy, and testing closer to delivery provides a more accurate representation of the client's GBS status at the time of labor. Option A) At the first prenatal visit is incorrect because GBS status can change over the course of pregnancy, so testing at the beginning may not reflect the client's status later on, closer to delivery. Option C) During the second trimester is also incorrect as GBS testing is typically recommended later in the third trimester to ensure the most up-to-date information. Option D) After 40 weeks' gestation is incorrect as testing at this late stage may not allow for appropriate interventions or treatments to prevent vertical transmission of GBS to the newborn. Educationally, understanding the rationale behind the timing of GBS testing helps nurses and healthcare providers deliver evidence-based care to pregnant clients, reducing the risk of neonatal GBS infection. It emphasizes the importance of timing in prenatal care and highlights the dynamic nature of certain maternal health conditions during pregnancy. This knowledge empowers nurses to advocate for appropriate testing protocols and interventions to promote positive maternal and neonatal outcomes.

Correct Answer: C

Rationale: In the context of educating a pregnant client about exercises during pregnancy, it is crucial to emphasize the importance of avoiding contact sports, which is the correct answer (C). Contact sports pose a risk of injury to both the mother and the developing fetus due to the physical nature of these activities. Pregnant women are advised to steer clear of activities that involve a high risk of falls, collisions, or direct impacts to the abdomen to safeguard the well-being of themselves and their baby. Walking (B) is generally considered a safe and beneficial form of exercise during pregnancy as it helps maintain cardiovascular fitness and can be easily adapted to individual fitness levels. Swimming (A) is another excellent low-impact exercise option for pregnant women as it provides a full-body workout without putting stress on the joints. Prenatal yoga (D) is also a popular choice as it focuses on gentle stretching, breathing techniques, and relaxation, which can help improve flexibility, strength, and mental well-being during pregnancy. Educationally, it is important to provide pregnant clients with specific guidance on safe and appropriate exercise options based on their individual health status, stage of pregnancy, and any obstetric considerations. Encouraging regular physical activity while highlighting the importance of avoiding high-risk activities like contact sports is essential for promoting a healthy pregnancy and optimal maternal and fetal outcomes.

Correct Answer: A

Rationale: In this scenario, the priority action for the nurse caring for a client at 38 weeks' gestation reporting decreased fetal movement is to perform a nonstress test (NST). This test monitors the fetal heart rate in response to fetal movement, helping assess fetal well-being quickly and non-invasively. Performing an NST is crucial because decreased fetal movement could indicate fetal distress or compromise, which requires immediate evaluation to prevent adverse outcomes. The NST provides real-time information on fetal well-being, guiding further interventions or decisions. Instructing the client to drink orange juice (Option B) is not the priority in this situation as it may temporarily increase fetal activity but does not provide a comprehensive assessment of fetal well-being like an NST does. Scheduling an ultrasound (Option C) is important for assessing fetal anatomy and growth but may not provide immediate information on fetal well-being compared to an NST. Notifying the healthcare provider immediately (Option D) is important but performing an NST first allows the nurse to provide timely data to the provider for informed decision-making. Educationally, understanding the importance of prompt assessment and intervention in cases of decreased fetal movement is crucial for nurses caring for pregnant clients to ensure optimal outcomes for both the mother and the baby.