A nurse is caring for a client who is pregnant.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Blood pressure
Urine ketones
Urine protein Gravida/parity
Report of headache
Respiratory rate
Fetal activity
Correct Answer : A,C,D,F
A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.
B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.
C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.
D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.
E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.
F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Crackles in the lungs are a common finding in heart failure due to pulmonary congestion and fluid accumulation.
B. Decreased thirst is not typically associated with heart failure.
C. Tachycardia can occur in heart failure but is not as specific as crackles for diagnosing fluid overload.
D. Poor skin turgor is more indicative of dehydration, not heart failure.
Correct Answer is C
Explanation
A. Storing oxygen tanks under the bed is not safe due to limited ventilation and fire hazards.
B. The oxygen gauge should be checked daily, not weekly, to monitor levels.
C. The oxygen tank should be placed away from curtains or drapes to reduce the risk of fire.
D. The oxygen tank wrench should be readily accessible in case of emergencies.
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