Practice Quiz

NCLEX-PN

Category - Physiological Adaptation

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The nurse is caring for a client at 36 weeks gestation. Assessment reveals a blood pressure measurement of 160/100, marked proteinuria, and 300 mL urine output in 24 hours. Based on these findings, which of the following is the best action of the nurse?
  1. Prepare the client for induced labor
  2. Initiate a sodium-restricted diet, as ordered
  3. Obtain the client’s blood pressure every 8 hours
  4. Enforce bed rest
Explanation
Answer: A - In a client with severe eclampsia but who is at 36 weeks gestation or more, induced labor can be initiated. If the client is less than 36 weeks gestation or if the fetal lung function is not mature, the nurse should initiate actions that alleviate the symptoms. The other options are not correct.
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