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 B
Explanation
A. Acute hemolytic: An acute hemolytic reaction typically presents with symptoms like fever, chills, back pain, hypotension, and hematuria. It is caused by the recipient’s immune system attacking incompatible donor red blood cells, not primarily by urticaria and wheezing.
B. Anaphylactic: An anaphylactic reaction is a severe allergic response to blood transfusion and is characterized by symptoms such as urticaria (hives), wheezing, hypotension, and respiratory distress. It requires immediate intervention, including stopping the transfusion and administering emergency medications.
C. Febrile: A febrile reaction is usually marked by fever, chills, and headache during or shortly after a transfusion. It does not typically involve wheezing or significant allergic skin reactions like urticaria.
D. Circulatory overload: Circulatory overload occurs when too much fluid is administered too quickly, leading to symptoms like dyspnea, cough, and pulmonary edema. While it involves respiratory symptoms, it is not associated with urticaria or allergic reactions.
Correct Answer is B
Explanation
A. "Let's review hormonal contraceptives first": Redirecting the conversation to hormonal contraceptives ignores the client’s expressed preference. Effective communication involves respecting client choices and supporting informed decision-making rather than pushing alternative methods first.
B. "I will provide you with more information about this": This response supports the client’s autonomy by offering information tailored to their expressed interest. Providing education about natural family planning, including techniques and effectiveness, allows the client to make an informed and empowered decision.
C. "Have you considered other alternatives": While exploring options is sometimes appropriate, immediately questioning the client's choice may feel dismissive. It is important to first respect and address the client's initial interest before introducing other possibilities if needed.
D. "Natural family planning is not beneficial for everyone.": Although this statement may be true in some cases, it is not an appropriate initial response. It risks discouraging the client prematurely rather than fostering an open, supportive discussion about how to use natural family planning effectively.
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