The nurse is assessing a newly admitted patient who is 32 weeks' gestation. The patient's chief complaints are sudden onset of intense nausea and a frontal headache for the past two days
The patient's initial blood pressure is 158/98 and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing?
1. Placing a wedge under the patient's left hip so that she is in a right lateral tilt position
2. Administration of diuretics and facilitating a dietary regimen of strict sodium restriction
3. Conducting a urine dipstick test to assess for proteinuria
4. Ordering a low-protein diet plan for the patient
Correct Answer: 3
Rationale 1: This patient's signs and symptoms are consistent with pre-eclampsia. Appropriate interventions include instituting bed rest with the patient positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion.
Rationale 2: This patient's signs and symptoms are consistent with pre-eclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating pre-eclampsia.
Rationale 3: This patient's signs and symptoms are consistent with pre-eclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria.
Rationale 4: This patient's signs and symptoms are consistent with pre-eclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/ day) to replace protein lost in the urine.
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