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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.
B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.
C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.
D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.
Correct Answer is C
Explanation
A. Urinary catheter: A urinary catheter is not routinely required for infants with a spica cast. Unless there are specific urinary retention issues or surgical complications, normal voiding is expected, and a catheter would introduce unnecessary risk for infection.
B. Wound vac: A wound vac is used for complex wound management involving significant drainage or delayed healing. Infants with a spica cast typically do not have open wounds that necessitate negative pressure wound therapy, making this equipment unnecessary for discharge.
C. Car seat: A special car seat or car bed is necessary for safe transportation of an infant in a spica cast, as standard car seats cannot accommodate the wide leg positioning. Proper fitting ensures both safety and compliance with transportation regulations during discharge.
D. Feeding pump: A feeding pump is typically used for clients requiring continuous enteral feeding. Unless the infant has a separate feeding disorder or gastrointestinal complication, feeding by mouth is expected, and a feeding pump would not be standard discharge equipment.
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