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 D

Explanation

A. Diabetes insipidus does not cause hypoglycemia, so this is not relevant.

B. Capillary refill time is unrelated to diabetes insipidus management.

C. A heart rate of 140/min is tachycardic and may indicate dehydration or other complications, not medication effectiveness.

D. Desmopressin reduces excessive urine output, and a cessation of nocturnal enuresis (bedwetting) indicates improved fluid balance and medication effectiveness.

A. "Take your temperature every night before going to bed." B. "Take your temperature 1 hour after getting out of bed." C. "Take your temperature immediately after waking and before getting out of bed." D. "Take your temperature within 30 minutes after your first morning void."

Correct Answer is C

Explanation

A. Take your temperature every night before going to bed: Nighttime readings are not basal body temperatures.

B. Take your temperature 1 hour after getting out of bed: This does not reflect the true basal temperature.

C. Take your temperature immediately after waking and before getting out of bed: This ensures an accurate basal temperature, as any activity can alter the reading.

D. Take your temperature within 30 minutes after your first morning void: BBT should be measured before any activity, including voiding.

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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.

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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.