A nurse is caring for a client who is at 34 weeks of gestation. The client has a medical history of gestational diabetes, preeclampsia with previous pregnancy, and chronic hypertension for 5 years. The client’s vital signs are: BP: 170/104 mm Hg, Pulse: 89/min, Respirations: 20/min, Temperature: 98.8°F (37.1°C) Oral, Oxygen saturation: 97% room air. The nurse is reviewing the client’s medical record to develop a plan of care.
What are the two most important nursing interventions for this client?
A.
Monitor the fetal heart rate and movement
B.
Administer magnesium sulfate as prescribed
C.
Encourage the client to drink plenty of fluids
D.
Educate the client about the signs of preterm labor
The Correct answer and Explanation is:
The two most important nursing interventions for this client are B. Administer magnesium sulfate as prescribed and A. Monitor the fetal heart rate and movement.
Explanation
B. Administer magnesium sulfate as prescribed:
Given the client’s elevated blood pressure (170/104 mm Hg) and history of preeclampsia, administering magnesium sulfate is crucial. Magnesium sulfate is often prescribed for clients with severe hypertension and preeclampsia to prevent seizures, which are a significant risk in these situations. It acts as a central nervous system depressant and has a neuroprotective effect, reducing the likelihood of eclamptic seizures. Additionally, magnesium sulfate can help lower blood pressure temporarily, although its primary role in this context is seizure prophylaxis. Monitoring the client for side effects, such as respiratory depression and decreased reflexes, is also essential during administration.
A. Monitor the fetal heart rate and movement:
Fetal monitoring is vital for assessing the well-being of the fetus, especially in high-risk pregnancies like this one. The elevated maternal blood pressure can affect uteroplacental perfusion, leading to potential fetal distress or growth restrictions. Regular monitoring of fetal heart rate patterns and movements helps identify any abnormalities early, allowing for timely interventions. Changes in fetal heart rate can indicate hypoxia or other complications, necessitating further evaluation and possibly expedited delivery.
While options C (encouraging fluid intake) and D (educating about signs of preterm labor) are important aspects of care, they do not address the immediate and critical risks presented by the client’s severe hypertension and history of preeclampsia. Therefore, focusing on magnesium sulfate administration and continuous fetal monitoring aligns with prioritizing the safety and health of both the mother and the fetus in this scenario.