A nurse is assisting with the care of a client who is pregnant
The nurse is reviewing the client's medical record.
Select 4 findings that the nurse should identify as a potential prenatal complication.
Urine protein
Respiratory rate
Gravida/parity
Urine ketones
Headache
Fetal activity
Blood pressure
Correct Answer : A,E,F,G
- Urine protein: The presence of 3+ proteinuria is a significant finding suggestive of preeclampsia. Protein in the urine indicates renal involvement due to endothelial dysfunction, which is a hallmark complication in hypertensive disorders of pregnancy and needs immediate attention.
- Respiratory rate: A respiratory rate of 16/min falls within the normal adult range of 12 to 20 breaths per minute. There is no evidence of respiratory distress, tachypnea, or bradypnea, so this finding does not suggest a prenatal complication.
- Gravida/parity: Although the client has a history of one preterm birth, gravida and parity alone are not indicators of a current prenatal complication. It is important background information but does not point directly to an acute complication at this time.
- Urine ketones: The absence of ketones in the urine is a normal finding. If ketones were present, it could suggest dehydration, starvation, or uncontrolled diabetes, but since they are negative, ketones are not a concern for prenatal complication here.
- Headache: A severe headache unrelieved by acetaminophen in a pregnant woman can signal worsening hypertension or preeclampsia. Persistent headaches are a concerning symptom that warrants immediate evaluation and management to prevent maternal and fetal harm.
- Fetal activity: Decreased fetal movement is a worrisome sign of possible fetal compromise, such as hypoxia or placental insufficiency. Reduced movements require further fetal assessment and monitoring to ensure fetal well-being.
- Blood pressure: A blood pressure reading of 162/112 mm Hg is severely elevated and meets the diagnostic criteria for severe preeclampsia. Uncontrolled hypertension during pregnancy places both the mother and fetus at significant risk for serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Take the medication with crackers: Taking doxycycline with food can help reduce gastrointestinal irritation, including nausea and vomiting. While it is not usually recommended to take doxycycline with food to ensure full absorption, in this case, eating crackers can help alleviate nausea and make the medication more tolerable.
B. Take the medication with an antacid: Antacids can interfere with the absorption of doxycycline, decreasing its effectiveness. Therefore, it is not recommended to take doxycycline with an antacid.
C. Take the medication and then lay down for 30 min: Lying down after taking doxycycline can increase the risk of esophageal irritation and ulceration. The medication should be taken while sitting or standing, and the client should remain upright for at least 30 minutes afterward.
D. Take the medication with calcium-fortified orange juice: Calcium can bind to doxycycline, decreasing its absorption and effectiveness. Therefore, it is not recommended to take doxycycline with calcium-fortified beverages.
Correct Answer is D
Explanation
A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.
B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.
C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.
D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.
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