A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?
2+ pitting edema of the lower extremities
Increased hemoglobin
Blood pressure 158/54 mm Hg
Client report of upper right quadrant pain
The Correct Answer is D
Rationale:
A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.
B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.
C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.
D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.
B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.
C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.
D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.
Correct Answer is B
Explanation
Rationale:
A. 1/2 cup of corn: While corn contains some folate, the amount is relatively low compared to legumes and leafy greens. It is not considered one of the best sources of folic acid for meeting the increased demands of early pregnancy.
B. 1/2 cup of cooked lentils: Lentils are among the richest natural sources of folic acid, providing a significant portion of the recommended daily intake. They are especially beneficial during early pregnancy to help prevent neural tube defects in the developing fetus.
C. 1 fried egg: Eggs provide a small amount of folate but are not a primary source. Although eggs offer other important nutrients during pregnancy, they do not meet the body’s high folic acid needs at 8 weeks gestation.
D. 1 slice of toast: Most bread products in some regions are fortified with folic acid, but the quantity in a single slice is minimal. While it can contribute to daily intake, it is not as concentrated a source as legumes like lentils.
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