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.
Fetal activity
Urine ketones
Urine protein
Report of headache
Respiratory rate
Blood pressure
Gravida/parity
Correct Answer : A,C,D,F
Rationale:
A. Fetal activity: Decreased fetal movement is an abnormal finding suggesting possible fetal distress or hypoxia. It indicates reduced oxygen or nutrient delivery to the fetus, often associated with maternal complications such as hypertension or preeclampsia. Immediate evaluation with fetal monitoring or ultrasound is warranted.
B. Urine ketones: The absence of urine ketones is expected and does not indicate a prenatal complication. Ketones would only be concerning if elevated, as they could signal dehydration, starvation, or poorly controlled diabetes, which is not present in this case.
C. Urine protein: The presence of 3+ protein in the urine is a key indicator of preeclampsia. Proteinuria results from endothelial damage in the kidneys caused by hypertension, leading to leakage of protein into the urine and confirming a serious pregnancy complication.
D. Report of headache: A severe, persistent headache unrelieved by acetaminophen suggests cerebral vasospasm related to preeclampsia. It reflects increased blood pressure affecting cerebral circulation and can precede seizures or eclampsia if untreated.
E. Respiratory rate: A respiratory rate of 16/min is within the normal range for adults and does not indicate a prenatal complication. There is no evidence of respiratory distress or metabolic abnormality in this finding.
F. Blood pressure: A reading of 162/112 mm Hg meets the diagnostic criteria for severe hypertension in pregnancy and strongly indicates preeclampsia. Uncontrolled elevated blood pressure increases the risk of seizures, placental abruption, and fetal growth restriction.
G. Gravida/parity: Being G3 P2 with one preterm birth is useful background information but not, by itself, a sign of a current complication. It helps identify obstetric history and risk factors but does not reflect an immediate prenatal concern in this assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Supplement breastfeedings with water every 12 hours.": Breastfed infants do not require water supplementation because breast milk provides adequate hydration. Giving water can reduce milk intake, interfere with nutrition, and increase the risk of electrolyte imbalance.
B. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding duration should be guided by the infant’s cues rather than a strict time limit. Limiting feeds can prevent the infant from receiving the hindmilk, which is richer in fat and essential for growth.
C. "Begin each feeding using the same breast.": Alternating the starting breast for each feeding helps ensure equal stimulation and milk production in both breasts. Starting with the same breast consistently may lead to uneven milk supply.
D. "Offer your infant the breast when he shows signs of hunger.": Responsive, cue-based feeding supports adequate nutrition, growth, and bonding. Feeding on demand—such as rooting, sucking on hands, or fussiness—helps establish and maintain milk supply and meets the infant’s needs effectively.
Correct Answer is D
Explanation
Rationale:
A. Beneficence: Beneficence involves promoting the well-being of clients. While both clients’ needs are important, the issue here is unequal access to resources, not the nurse’s intent to benefit them.
B. Autonomy: Autonomy relates to the client’s right to make informed decisions about their own care. The situation does not interfere with either client’s ability to make choices.
C. Nonmaleficence: Nonmaleficence means avoiding harm. Although delayed access to supplies could indirectly cause harm, the primary ethical concern is the fairness in distribution, not direct harm by action.
D. Justice: Justice involves fairness and equitable treatment. Providing supplies to one client based on insurance status while requiring the other to obtain them elsewhere reflects unequal treatment and a breach of the principle of justice.
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