Davis’s NCLEX-RN REVIEW - Complete Exam

No symptoms even with physical activity II Comfortable at rest with symptoms during ordinary physical activity III Comfortable at rest with symptoms during less than ordinary physical activity IV Symptoms at rest 1. Obtain additional evening rest. 2. Prevent and/or obtain early treatment of infections. 3. Anticipate vaginal delivery with regional block and forceps. 1. Avoid strenuous exercise. 2. Administer prophylactic penicillin, digitalis, diuretics. 3. Obtain frequent rest periods. 4. Anticipate vaginal delivery with regional block, oxygen, forceps. 1. Reduce physical activity. 2. Avoid emotional stress. 3. Administer penicillin, digitalis, diuretics. 4. Facilitate early hospitalization and delivery. 5. Anticipate recommendation of early therapeutic abortion. 1. Anticipate recommendation of early therapeutic abortion; 50% mortality associated with delivery. 2. Administer penicillin, digitalis, diuretics, rotating tourniquets. 3. Prepare for vaginal delivery. 2. Physiological integrity A. Maintain isolation precautions. 3. Psychosocial integrity A. Provide opportunities for counseling. 4. Health promotion and maintenance A. Provide education for self-care regarding isolation pre- cautions and prevention of infection. Implementation 1. Observe blood and body-secretion precautions, and teach precautions to client. 2. Maintain isolation to protect client from other organisms. 3. Follow blood and secretion precautions during all contact with expectant woman (antepartal, intrapartal, postpartal) and for the newborn infant. 4. Provide education regarding disease process and greatly decreased risk of transmission to the newborn if treated with Zidovidine in the last trimester of pregnancy. Evaluation Ensure that the expectant woman: 1. Is protected from further infection. 2. Participates in maintaining blood and body-secretion iso- lation. 3. Is able to verbalize her feelings about her condition. 4. Verbalizes knowledge of disease condition and implica- tions for the future. Hypertension Description Hypertension is elevated blood pressure occurring during the second trimester in the absence of preeclamptic symptomatol- ogy. This is regarded as essential hypertension unmasked by pregnancy and is generally permanent. Assessment PHYSICAL ASSESSMENT Assess for the following clinical manifestations: 1. Blood pressure elevation to 140/90 if no preexisting hy- pertension. 2. Retinal changes demonstrate arterial-venous nicking. PSYCHOSOCIAL AND CULTURAL ASSESSMENT 1. Hypertension occurs more frequently in older multipara. 2. American black women experience a higher incidence. 3. Woman may grieve about the lifelong nature of hyperten- sion. Planning 1. Safe, effective environment A. Monitor blood pressure on routine basis. 2. Physiological integrity A. Promote maternal-fetal well-being. 3. Psychosocial integrity A. Provide counseling and support 4. Health promotion and maintenance A. Provide education for self-care. Implementation 1. Assess blood pressure every 2 weeks for the first 2 trimesters, then weekly until birth. 2. Assessweight;testurineforprotein,indicatingpreeclamp- sia; report abnormalities to physician. 3. Administer and instruct regarding drug therapy. A. Antihypertensive drugs: methyldopa (Aldomet) B. Avoid diuretics unless the benefits outweigh the risks. 4. Instruct regarding nature, progress of disease. 5. Encourage frequent rest periods. 6. Counsel to avoid undue stress. 60 Clinical Specialties: Content Reviews and Tests 7. Provide diet instruction. A. No added salt diet B. High protein C. Maintain fluid intake. D. Routine prenatal nutrition 8. Anticipate early vaginal or cesarean birth. Evaluation Ensure that expectant woman: 1. Remains normotensive. 2. Progresses to birth with no further complications, as does the fetus. 3. Verbalizes support. 4. Verbalizesknowledgeofself-caremeasures,treatmentreg- imen, balanced activity and rest, and information regard- ing her medication. Disorders That Develop During Pregnancy Pregnancy-Induced Hypertension Description Pregnancy-induced hypertension is a set of symptoms occur- ring during pregnancy, which include edema, hypertension, proteinuria, convulsions, and coma. Eclampsia occurs at the point of convulsions. Etiology is unclear but appears to be as- sociated with reduced uteroplacental blood flow. Assessment PHYSICAL ASSESSMENT Assess for clinical manifestations (Table 3–21). PSYCHOSOCIAL AND CULTURAL ASSESSMENT 1. American blacks have a higher incidence of PIH for age, parity, and familial incidence. 2. PIH occurs more frequently in young primiparous women and multiparous women older than the age of 35. 3. Predisposing factors include inadequate protein intake, multiple pregnancy, hydatidiform mole, and chronic renal and vascular disease. Planning 1. Safe, effective care environment A. Prevent progression of PIH to convulsions. 2. Physiological integrity A. Monitor maternal and fetal well-being. 3. Psychosocial integrity A. Provide counseling and support. 4. Health promotion and maintenance A. Provide teaching related to self-care measures. Implementation 1. Facilitateearlyprenatalassessment,especiallyamonghigh- risk groups. 2. Assess physical parameters. A. Blood pressure. B. Weight. C. Urine for protein. D. Edema of face, hands, pretibial area. E. Check reflexes for hyperreflexia. 3. Provide diet instruction and assess compliance. A. AdequateNa;avoidaddedsaltandhighsodiumfoods. B. Maintain fluid intake. C. Ensure high protein intake (1 g/kg per day). D. Maintain good prenatal nutrition. 4. Instruct regarding medications. A. Antihypertensive drugs: Aldomet, Apresoline B. Sedation:phenobarbital;avoidValiumasitisassociated with an increased risk of aspiration if seizures occur. 5. Facilitate hospitalization, if required. 6. Promote bed rest, rest on left side, quiet environment. 7. Prevent convulsions. A. Administer magnesium sulfate (MgSO4) loading dose (4–6 g) and maintain at 1–2 g/hr (given IV by infused pump). B. Obtain MgSO4 blood levels at least every 4 hours. C. Use fetal monitor for continuous FHR tracing. D. Assess urine output, proteinuria, vital signs, reflexes, and respiratory effort hourly. E. Administer calcium gluconate for MgSO4 overdose. F. Prepare for labor induction or cesarean birth. G. Continue MgSO for 24 hours after birth. 4 Evaluation Ensure that expectant woman: 1. Complies with treatment regimen and does not develop eclampsia. 2. Progresses to birth without further complications, as does her baby. 3. Verbalizes support and increased coping ability. 4. Verbalizes self-care measures. Table 3–21. Symptomatology of Preeclampsia and Eclampsia Symptom Preeclampsia Eclampsia Edema Proteinuria Weight gain Blood pressure Other Mild to moderate, pretibial area Trace, 1