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 D
Explanation
The correct answer is choiced. “Limit the number of choices for the client.”
Choice A rationale:
Using written signs to assist the client with locating the bathroom can be helpful, but it is not the most critical strategy for managing Alzheimer’s disease.
Choice B rationale:
Providing a stimulating environment for the client can sometimes lead to overstimulation, which may increase confusion and agitation in clients with Alzheimer’s disease.
Choice C rationale:
Using confrontation to manage the client’s behavior is not recommended as it can lead to increased agitation and aggression.
Choice D rationale:
Limiting the number of choices for the client helps reduce confusion and anxiety, making it easier for them to make decisions and feel more in control.
Correct Answer is C
Explanation
Choice A rationale:
Epinephrine is not typically used to treat nausea. Nausea is usually managed with antiemetic medications.
Choice B rationale:
Epinephrine is not used to treat hand tremors. Hand tremors may be related to various conditions, and their management would depend on the underlying cause.
Choice C rationale:
The correct manifestation that epinephrine can help treat is "Swelling of the lips." Epinephrine is commonly used to treat severe allergic reactions (anaphylaxis), which can cause swelling of the lips, tongue, and throat. Epinephrine helps to reverse these symptoms by constricting blood vessels and opening the airways.
Choice D rationale:
Epinephrine is not used to treat hyperglycemia. Hyperglycemia is managed with insulin or other antidiabetic medications, not epinephrine.
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