Difficulty: Medium
Average Score: 93%
Simulated
Passage / Scenario
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.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. What are the two most important nursing interventions for this client?
Correct answer
A, B
Rationale
Monitoring fetal heart rate and movement assesses fetal well-being, critical due to high-risk conditions. Administering magnesium sulfate prevents seizures in severe preeclampsia, addressing the client's high blood pressure and history.