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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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

A. Perform intermittent external electronic fetal monitoring. B. Monitor vital signs at least every 15 min. C. Place the client in a supine position. D. Obtain type and crossmatch. E. Measure blood loss by weighing pads. F. Insert a large-bore IV catheter.

Correct Answer is ["B","D","E","F"]

Explanation

Choice A rationale:

Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.

Choice B rationale:

Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.

Choice C rationale:

Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.

Choice D rationale:

Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.

Choice E rationale:

Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.

Choice F rationale:

Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

Correct Answer is ["B","D","E","F"]

Explanation

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A nurse is collecting data for a client who is receiving enteral tube feedings.The nurse should identify that which of the following findings is a manifestation of fluid overload?