A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
A.
Restrict protein intake to less than 40 g/day.
B.
Initiate seizure precautions for the client.
C.
Initiate an infusion of 0.9% sodium chloride at 150 ml/hr.
D.
Encourage the client to ambulate twice per day.
The Correct Answer and Explanation is:
B. Initiate seizure precautions for the client.
Explanation:
Preeclampsia with severe features is a serious pregnancy complication characterized by high blood pressure and signs of organ dysfunction that can significantly affect both the mother and fetus. This condition can progress to eclampsia, which is characterized by seizures. Therefore, one of the critical interventions for a client with severe preeclampsia is to initiate seizure precautions.
Initiate Seizure Precautions: Seizure precautions are crucial for clients with severe preeclampsia due to the risk of developing eclampsia. This involves several measures:
- Monitoring: Frequent monitoring of the client’s neurological status, including any signs of impending seizures such as severe headache, visual disturbances, or altered mental status.
- Safety Measures: Ensuring that the environment is safe to prevent injury in the event of a seizure. This may include padding the side rails of the bed, having suction equipment available, and ensuring that the client’s bed is in the lowest position to prevent falls.
- Medication: Administering antiepileptic medications if prescribed by the healthcare provider, such as magnesium sulfate, which is commonly used to prevent seizures in severe preeclampsia.
Why Not the Other Options?
- A. Restrict protein intake to less than 40 g/day: Dietary protein restriction is not a recommended practice in managing severe preeclampsia. Instead, a balanced diet that supports overall maternal and fetal health is encouraged, and protein intake should be sufficient to meet nutritional needs.
- C. Initiate an infusion of 0.9% sodium chloride at 150 ml/hr: While fluid management is important, the rate and type of fluid infusion should be tailored to the client’s specific needs and monitored closely. A standard infusion rate might not address the specific issues related to severe preeclampsia and could potentially worsen the condition if not carefully managed.
- D. Encourage the client to ambulate twice per day: Ambulation is generally beneficial in pregnancy but may not be advisable in severe preeclampsia due to the risk of complications such as worsening hypertension or potential for falls. Bed rest and limited activity are often recommended to reduce the risk of complications.
In summary, initiating seizure precautions is essential for a client with severe preeclampsia to prevent potential seizures and ensure safety.