A nurse is caring for a client who is at 33 weeks of gestation.
Medical History Gravida 2 Para 1 Preeclampsia
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.
Platelet count 90.000/mm3
Hematuria
Positive clonus
Proteinuria 2+
Leukorrhea
BUN 40 mg/dL
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"C"}}
Platelet count 90,000/mm3: Sign of Potential Worsening Condition - A decreased platelet count may indicate worsening preeclampsia and a risk of developing HELLP syndrome or thrombocytopenia.
Hematuria: Sign of Potential Worsening Condition - Hematuria suggests potential kidney involvement, which is a serious complication of preeclampsia, indicating a worsening condition. Positive clonus: Sign of Potential Worsening Condition - Positive clonus is a neurological sign associated with preeclampsia and indicates hyperreflexia, which can lead to seizures if untreated. Proteinuria 2+: Sign of Potential Worsening Condition - Increased proteinuria indicates ongoing kidney dysfunction, which is a worsening sign of preeclampsia.
Leukorrhea: Sign of Potential Improvement - Leukorrhea, an increase in vaginal discharge, may indicate a reduction in cervical mucus plug, which is a normal finding in late pregnancy.
BUN 40 mg/dL: Sign of Potential Worsening Condition - Elevated blood urea nitrogen (BUN) levels indicate impaired kidney function, which is a worsening sign of preeclampsia and can lead to complications such as acute kidney injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Airborne precautions are used for diseases transmitted by airborne droplet nuclei smaller than 5 microns, such as tuberculosis. MRSA is not transmitted via airborne route.
B. Protective environment is used for clients who are immunocompromised, such as those undergoing bone marrow transplantation. It is not indicated for MRS
A.
C. Contact precautions are indicated for MRSA, as it is primarily transmitted through direct or indirect contact with an infected individual or contaminated environment.
D. Droplet precautions are used for diseases transmitted by large droplets (>5 microns), such as influenza or pertussis. MRSA is not transmitted via droplets.
Correct Answer is C
Explanation
Rationale:
A. This question addresses pelvic pressure, which may not directly relate to the effectiveness of the hands-and-knees position for occipitoposterior fetal positioning.
B. The spacing of contractions is not typically affected by maternal positioning and therefore is not the most appropriate question to evaluate the effectiveness of this intervention.
C. Asking about improvement in back labor is pertinent because the hands-and-knees position can help alleviate back pain associated with occipitoposterior fetal positioning.
D. Suprapubic pain is not typically associated with occipitoposterior fetal positioning, so this question may not provide useful information regarding the effectiveness of the intervention.
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