A nurse is assisting with the care of a client who is pregnant.
Nurses' Notes.
0900: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.
Client also reports urinary frequency and decreased fetal movement.
Client is a. gravida 3, para 2 with one preterm birth.
The nurse is reviewing the client's medical record.
Select 4 findings that the nurse should identify as a potential prenatal complication
Blood pressure.
Respiratory rate.
Gravida/parity.
Fetal activity.
Headache.
Urine ketones.
Urine protein.
Correct Answer : A,D,E,G
Choice A rationale:
Blood pressure is a crucial parameter to monitor in a pregnant woman. A significant increase in blood pressure could indicate a condition called preeclampsia, which is characterized by high blood pressure and damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby.
Choice B rationale:
While the respiratory rate is an important vital sign, it does not directly indicate a prenatal complication in this context. Normal respiratory rates for an adult range from 12 to 20 breaths per minute. Changes could indicate a respiratory problem but not specifically a prenatal complication.
Choice C rationale:
Gravida/parity is a standard way to denote a woman's reproductive history but does not indicate a prenatal complication. Gravida refers to the number of times a woman has been pregnant, regardless of the outcome, while parity refers to the number of pregnancies carried past 20 weeks, regardless of whether they were born alive or stillborn.
Choice D rationale:
Decreased fetal activity can be a sign of distress in the fetus. It could indicate complications such as poor oxygenation or other conditions that could affect the health of the baby. It's important for pregnant women to monitor their baby's movements daily after 28 weeks.
Choice E rationale:
A severe headache unrelieved by acetaminophen in a pregnant woman could be a sign of preeclampsia, especially when accompanied by other symptoms such as high blood pressure and changes in vision. This should be evaluated immediately.
Choice F rationale:
Urine ketones are usually checked in pregnant women who have symptoms of a condition called ketoacidosis, which is often seen in women with gestational diabetes. However, this condition is not indicated in this scenario.
Choice G rationale:
Protein in the urine is another potential sign of preeclampsia. It's caused by kidney problems resulting from the high blood pressure. In normal conditions, protein should not be present in urine or should be very low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B. Determine the acuity and number of casualties arriving at the facility.
Choice A rationale: Assisting in discharging stable clients to home is important but not the primary focus during the immediate response to a mass casualty event.
Choice B rationale: Determining the acuity and number of casualties arriving at the facility is crucial in a mass casualty event. This involves assessing the severity of injuries and prioritizing care based on urgency, ensuring that the most critical patients receive immediate attention.
Choice C rationale: Delegating tasks to emergency health care specialists is typically the responsibility of team leaders or incident command staff, not the medical-surgical unit nurses.
Choice D rationale: Providing informational updates to members of the media is generally managed by hospital administration or public relations staff, not by medical-surgical nurses.
Correct Answer is D
Explanation
Choice A rationale:
"I should use the cap during my menstrual cycle to prevent pregnancy." Rationale: This statement is incorrect. The cervical cap should be used only during sexual intercourse to prevent pregnancy, not during the menstrual cycle. It does not provide protection against sexually transmitted infections (STIs) and should be used in conjunction with a spermicide for effectiveness.
Choice B rationale:
"I should avoid using spermicide with the cervical cap." Rationale: This statement is incorrect. To enhance the effectiveness of the cervical cap, it should be used with a spermicide. Spermicide helps immobilize and kill sperm, providing an additional barrier against pregnancy.
Choice C rationale:
"I need to have my provider check the size of the cap every 6 months." Rationale: This statement is incorrect. While it's important for the healthcare provider to properly fit the cervical cap initially, it does not require routine sizing checks every six months. However, clients should periodically check the cap for any signs of damage or deterioration.
Choice D rationale:
"I need to keep the cap in place for at least 6 hours after intercourse." Rationale: This is the correct statement. To ensure the effectiveness of the cervical cap, it should be left in place for at least six hours after intercourse. It provides a barrier that prevents sperm from reaching the cervix. However, it should not be left in place for more than 48 hours to reduce the risk of toxic shock syndrome.
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