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 D
Explanation
A. A face shield is unnecessary unless there is a risk of splashing.
B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.
C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.
D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.
Correct Answer is A
Explanation
A. Using an ultrasound picture as a focal point is an effective nonpharmacological distraction technique for managing labor pain.
B. Biofeedback requires prior training and is not typically initiated during labor.
C. Acupuncture requires a specialist and is not commonly initiated by nurses during labor.
D. Transcutaneous electrical nerve stimulation (TENS) is typically used for back pain rather than pelvic pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.