A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?
Elevated blood pressure
Increased urine output
Joint pain
Vaginal discharge
The Correct Answer is A
Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.
Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.
Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.
Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: To stay with the client and call for help is the highest priority during a seizure, because it ensures the safety of the client and the fetus, and allows the nurse to monitor the vital signs and fetal heart rate. The nurse should also protect the client from injury and turn the client to the side to prevent aspiration.
Choice B reason: To suction the mouth to prevent aspiration is not the highest priority during a seizure, because it can cause more harm than good. Suctioning can stimulate the gag reflex and increase the risk of vomiting and aspiration. It can also injure the oral mucosa and trigger another seizure.
Choice C reason: To administer oxygen by mask is not the highest priority during a seizure, because it may not be effective or necessary. Oxygen administration can be difficult or impossible during a seizure, and it may not improve the oxygen saturation or fetal outcome. Oxygen should only be given if hypoxia is confirmed by pulse oximetry or arterial blood gas analysis.
Choice D reason: To insert an oral airway is not the highest priority during a seizure, because it can be dangerous and contraindicated. Inserting an oral airway can damage the teeth and tongue, and increase the risk of vomiting and aspiration. It can also provoke another seizure or laryngospasm. An oral airway should only be used if the client is unconscious and has no gag reflex.
Correct Answer is A
Explanation
Choice A reason: A client who is experiencing preterm labor at 26 weeks of gestation is a suitable candidate for tocolytic therapy, because it can help delay the delivery and allow time for fetal lung maturation and transfer to a tertiary care center. Tocolytic therapy is indicated for clients who have regular uterine contractions and cervical changes before 37 weeks of gestation.
Choice B reason: A client who is experiencing fetal death at 32 weeks of gestation is not a suitable candidate for tocolytic therapy, because it has no benefit for the mother or the fetus. Tocolytic therapy is contraindicated for clients who have fetal demise, as it can increase the risk of infection and coagulation disorders.
Choice C reason: A client who has a post-term pregnancy at 42 weeks of gestation is not a suitable candidate for tocolytic therapy, because it can harm the mother and the fetus. Tocolytic therapy is contraindicated for clients who have post-term pregnancy, as it can increase the risk of placental insufficiency, fetal distress, and meconium aspiration.
Choice D reason: A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation is not a suitable candidate for tocolytic therapy, because it is not necessary or effective. Braxton-Hicks contractions are irregular and painless contractions that do not cause cervical changes or labor. They are normal and harmless, and do not require any intervention.
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