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 A
Explanation
Choice A rationale:
The nurse's first action when caring for a client with bulimia nervosa should be to observe the client during and after meals. This is essential to monitor for signs of binge-eating followed by compensatory behaviors such as vomiting or the misuse of laxatives. Timely observation can help ensure the client's safety and provide an opportunity for immediate intervention if necessary.
Choice B rationale:
Suggesting that the client assist with meal planning can be a beneficial intervention, but it should not be the first action. Clients with bulimia nervosa often have complex emotional and psychological issues related to their eating habits, so it's crucial to address the immediate risks of binge-purge episodes before moving on to meal planning.
Choice C rationale:
Instructing the client about effective coping strategies is important for long-term recovery, but it should not be the first action. Immediate safety concerns, such as monitoring for binge-purge behaviors, take precedence in the initial care of a client with bulimia nervosa.
Choice D rationale:
Referring the client to a support group is a valuable intervention in the long-term management of bulimia nervosa, but it should not be the first action. The immediate priority is to assess and address any acute risks associated with the disorder, such as binge-purge episodes.
Correct Answer is B
Explanation
Choice A rationale:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
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