58. A woman, who is 36 weeks pregnant, is admitted directly from clinic with a blood pressure of 146/98 mm Hg, puffy face and hands, and "awful headaches and problems seeing." The admission note states: "Admit for preeclampsia." Which nursing orders should not be implemented? Select all that apply.
. Up as desired, activities as desired.
. Assess deep tendon reflexes, and amount and distribution of edema on every shift.
. Admission and daily weight.
. Test urine for protein every 4 hours.
. Intake and output on every shift.
Test-Taking Tip
This question asks for the wrong action. Four of the options are appropriate orders; select the one that is not.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Illness Management
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Answer 1 is correct because, if possible, women hospitalized for treatment of preeclampsia should be on bedrest in a quiet environment to minimize stimuli. Answer 2 is incorrect because the nurse should assess the amount and distribution of edema. Answer 3 is incorrect because weight is an indicator of edema and diuresis and should be assessed in the woman with preeclampsia. Answer 4 is incorrect because the presence and amount of protein in the urine are important indicators of her status. Answer 5 is incorrect because I&O relationships are important indicators of her status.