The nurse is assessing a newly admitted patient who is 32 weeks' ...

[Mimi]

The nurse is assessing a newly admitted patient who is 32 weeks' gestation. The patient's chief complaints are sudden onset of intense nausea and a frontal headache for the past two days.
 
  The patient's initial blood pressure is 158/98 and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing?
  1. Placing a wedge under the patient's left hip so that she is in a right lateral tilt position
  2. Administration of diuretics and facilitating a dietary regimen of strict sodium restriction
  3. Conducting a urine dipstick test to assess for proteinuria
  4. Ordering a low-protein diet plan for the patient

Question 2

A patient who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing?
 
  1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM) to the patient
  2. Notify the patient's primary care provider and document the potential need for treatment of fetal hemolytic anemia in the patient's baby after delivery.
  3. Obtain an antibody screen (indirect Coombs' test) to determine whether the patient has developed isoimmunity.
  4. Note the potential for ABO incompatibility and plan to carefully assess the patient's neonate for the development of hyperbilirubinemia.

[shaquita]

Answer to Question 1

Correct Answer: 3
Rationale 1: This patient's signs and symptoms are consistent with pre-eclampsia. Appropriate interventions include instituting bed rest with the patient positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion.
Rationale 2: This patient's signs and symptoms are consistent with pre-eclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating pre-eclampsia.
Rationale 3: This patient's signs and symptoms are consistent with pre-eclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria.
Rationale 4: This patient's signs and symptoms are consistent with pre-eclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/ day) to replace protein lost in the urine.

Answer to Question 2

Correct Answer: 4
Rationale 1: RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood.
Rationale 2: Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia.
Rationale 3: An antibody screen (indirect Coombs' test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen.
Rationale 4: Unlike Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert caregivers to the need for carefully assessing the newborn for the development of hyperbilirubinemia.