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","C","D","E"]
Explanation
The correct answers are Choices B, C, D, and E.
Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.
Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.
Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.
Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.
Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.
Correct Answer is D
Explanation
Following a subtotal thyroidectomy, the nurse should position the client in a way that minimizes strain on the surgical site and promotes respiratory function. The most appropriate position for this client is:
d) Semi-Fowler's.
Semi-Fowler's position, where the head of the bed is elevated at a 30 to 45-degree angle, helps reduce swelling at the surgical site and facilitates breathing. This position also minimizes tension on the suture line and aids in preventing strain on the neck.
The other options are not as suitable for post-thyroidectomy positioning:
a) Dorsal recumbent: This position involves lying on the back with the knees flexed. While it might be used in some situations, it doesn't specifically address the considerations after a thyroidectomy.
b) Supine: Lying flat on the back may not provide optimal support to the neck and could potentially increase discomfort.
c) Left lateral: Lying on the left side may not be as effective in reducing strain on the neck and surgical site compared to the semi-Fowler's position.
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