A nurse is caring for a client who is pregnant.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential prescription	Anticipated	Contraindicated
Bupropion 100 mg PO three times daily		✓
Levomilnacipran 20 mg PO daily	✓
Citalopram 20 mg PO daily	✓
Fluoxetine 20 mg PO daily	✓

Rationale

Bupropion 100 mg PO three times daily: Contraindicated
- Bupropion is generally contraindicated for clients with a history of bulimia nervosa due to the increased risk of seizures.
Levomilnacipran 20 mg PO daily: Anticipated
- Levomilnacipran is an SNRI that can be used to treat major depressive disorder and is generally safe for clients with bulimia nervosa.
Citalopram 20 mg PO daily: Anticipated
- Citalopram is an SSRI commonly used to treat major depressive disorder and can be effective for clients with bulimia nervosa.
Fluoxetine 20 mg PO daily: Anticipated
- Fluoxetine is an SSRI that is effective in treating both major depressive disorder and bulimia nervosa.

A. Caffeine use B. Evening meal C. Use of electronic devices D. Exercise schedule E. Bedtime Medications

Correct Answer is ["A","C"]

Explanation

A. Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B. While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C. The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D. Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E. The medications taken by the individual do not interfere with sleep.

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A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse is caring for a client in an outpatient clinic. Exhibits Select the 2 findings the nurse should identify as factors that may interfere with the client's sleep.

Correct Answer is ["A","C"]

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A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.