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Author Question: A health care provider reports to the labor nurse that a patient is being transferred from the ... (Read 117 times)

Caiter2013

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A health care provider reports to the labor nurse that a patient is being transferred from the clinic directly to the hospital with possible preeclampsia. What is the nurse's priority action when the patient is admitted?
 
  a. Obtain the patient's weight.
  b. Take the patient's vital signs.
  c. Start an IV with lactated Ringer's at 75 mL/hr.
  d. Ask support persons to leave the birthing room.

Question 2

The nurse is providing care to a patient who just learned her baby has died in utero at 26 weeks' gestation. What is the nurse's next action?
 
  a. Contact the patient's clergy member.
  b. Enroll the patient in a grief and loss class.
  c. Determine if the patient is a victim of violence.
  d. Ask the patient when she last felt the baby move.



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gcook

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Answer to Question 1

ANS: B
The hallmark signs of preeclampsia are hypertension and proteinuria. These parameters must be evaluated first. Obtaining the patient's weight may indicate excess fluid gain, but fluid retention does not occur in all cases of preeclampsia. An IV will be beneficial; however, assessment precedes implementation in this case to obtain baseline data. Promoting a nonstimulating environment can help decrease blood pressure; however, loss of support during this frightening time can increase anxiety in this initial assessment phase and actually increase the patient's blood pressure.

Answer to Question 2

ANS: D
Determining fetal movement will give the nurse a basis for how long the fetus has been expired. This patient is at risk for developing DIC, and the longer the fetus has been expired, the greater the risk. All the interventions listed are worth considering for this patient; however, the nurse must meet the patient's immediate physical needs first.





 

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