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 A
Explanation
A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.
B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.
C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.
D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.
Correct Answer is B
Explanation
Rationale:
A. Gestational diabetes mellitus is not a contraindication for a contraction stress test.
B. A previous classical incision (a vertical uterine incision) increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.
C. A previous stillbirth is not a contraindication for a contraction stress test.
D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test, but it is not a contraindication in itself.
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