A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
Blood glucose 110 mg/dL.
Urine protein of 3+.
Hemoglobin 13 g/dL.
Deep tendon reflexes of 2+.
The Correct Answer is B
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.
Choice B rationale:
Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.
Choice C rationale:
Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.
Choice D rationale:
Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.
Correct Answer is C
Explanation
Choice Arationale:
Offering the client a sitz bath may provide some relief, but it does not address the underlying issue of bladder distention. The priority is to address the bladder distention directly.
Choice Brationale:
Inserting a urinary catheter is not the first-line intervention for bladder distention after vaginal birth. Catheterization carries a risk of infection and trauma, so it should only be done if other interventions are not effective.
Choice C rationale:
Assisting the client to the bathroom is the first action the nurse should take. Bladder distention can occur after birth due to the pressure on the bladder during labour and birth. Encouraging the client to empty her bladder will relieve the distention and promote comfort.
Choice D rationale:
Pouring warm water over the client's perineum might provide some comfort, but it does not address the bladder distention itself.
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