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Initial History and Assessment
At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The client complains of a pounding headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad heartburn. Her sister tells the nurse, "I felt like that when I had toxemia during my pregnancy."
Admission assessment by the nurse reveals: today's weight 182 pounds, T 99.1° F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the urine. Heart rate is regular, and lung sounds are clear. Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus.[pic][pic]
The nurse applies the …show more content…
She asks the nurse if the healthcare provider will prescribe some of "those water pills" (diuretics) to help get rid of the excess fluid.
4. Which response by the nurse is correct?
[pic]A) "That is a very good idea. I will relay it to the healthcare provider when I call."
[pic]B) "I'm sorry, but it is not the family's place to make suggestions about medical treatment."
[pic]C) "Let me explain to you about the effect of diuretics on pregnancy."
[pic]D) "Have you by any chance given your sister water pills that belong to someone else?"
Admission to the Labor and Delivery Unit
At 0630 the nurse calls to report to the healthcare provider, who prescribes the following: admit to labor and delivery, bedrest with bathroom privileges (BRP), IV D5LR at 125 ml/hr, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital signs, and DTRs.
5. While awaiting the lab results, which nursing intervention has the highest priority?
[pic]A) Teach Jennie the rationale for bedrest.
[pic]B) Monitor Jennie for signs of dehydration.
[pic]C) Educate the client about dietary restrictions.
[pic]D) Observe Jennie for CNS changes.
6. Which technique is best for the nurse to use when evaluating Jennie's blood pressure while she is on bedrest?
[pic]A) Have Jennie lay supine and take the blood pressure on the left arm.
[pic]B) Have Jennie lie in a