Question

Assessment data: T 36.5 C, 97.2 F, Pulse 88 and regular, BP 150/94 R arm, 148/96 L arm. Baseline FHR 144. Reactive NST with no fetal decelerations. Heart sounds regular, no heart murmur or extra sounds. Breath sounds clear bilaterally +3 peripheral edema, +3 reflexes. States pain level 5/10- ""headache increasing"". Labs are ordered and drawn, and intravenous access is obtained. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

a. Turn the client to her left side and offer prescribed acetaminophen.Left lateral recumbent position decreases pressure on vena cava, therefore increasing venous return and placental and renal perfusion. Acetaminophen to relieve headache.
b. Elevate and pad side rails.Her DTRs are +3 so she has slightly hyperreflexia and is at risk for seizures. Padding side rails protects her from injury if she has a seizure.
c. Apply oxygen at 10 L/min per mask.Minimal fetal variability may be related to fetal hypoxemia so applying oxygen to the mother increases perfusion to fetus. Reactive NST is reassuring so fetus may be in sleep cycle but oxygen to mother won't harm and might help.
d. Emergency medications brought to the client's room/verify accessibility.Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are often in an emergency ""toolbox"" and brought to client's room for immediate access if needed; have available before calling HCP, anticipating one or more of these meds will be prescribed. Practice depends upon agency policy.
e. Notify healthcare provider of assessments.After doing all of these interventions to help the client and fetus quickly, notify the healthcare provider of the status change.

Answer 1

The first two nursing actions should be to turn the patient to her left side to improve circulation and relieve discomfort and to elevate and pad side rails as a safety precaution due to signs of potential seizure activity.

Step-by-step explanation:

The first nursing action should be to turn the client to her left side and offer prescribed acetaminophen. This position can help improve placental and renal perfusion by decreasing pressure on the vena cava. Given the patient's headache and elevated blood pressure, this action can address discomfort and potentially improve circulation. Furthermore, acetaminophen can help alleviate the pain from the headache.

The second nursing action should be to elevate and pad side rails. The patient's +3 reflexes suggest hyperreflexia, which is a sign of potential seizure activity. Padding the side rails is a precautionary measure to protect the patient from injury in the event of a seizure.