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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.

Fetal activity

Urine ketones

Urine protein

Report of headache

Respiratory rate

Blood pressure

Gravida/parity

Answer and Explanation

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.

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Correct Answer is C

Explanation

Rationale:
A. Hemothorax: Hemothorax is accumulation of blood in the pleural space, typically caused by trauma, surgery, or ruptured vessels. Atrial fibrillation does not directly increase the risk of hemothorax.

B. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, impairing cardiac output. This condition is usually associated with trauma, pericarditis, or post-surgical complications, not atrial fibrillation.

C. Pulmonary emboli: Atrial fibrillation can lead to stasis of blood in the atria, especially the left atrial appendage, increasing the risk of thrombus formation. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, making this a serious complication to monitor for.

D. Widened pulse pressure: Widened pulse pressure reflects the difference between systolic and diastolic blood pressure and is associated with conditions like aortic regurgitation. It is not a direct consequence of atrial fibrillation and is not considered a primary risk in these clients.

A. Call the pharmacist for clarification of the medication contraindications. B. Administer the medication as prescribed. C. Discuss the prescription with the health care provider. D. Place an incident report in the medical record.

Correct Answer is C

Explanation

Rationale:
A. Call the pharmacist for clarification of the medication contraindications: While the pharmacist can provide medication information, it is the provider’s responsibility to evaluate the appropriateness of the prescription and modify it if needed.

B. Administer the medication as prescribed: Administering amoxicillin to a client allergic to penicillin places the client at risk for an allergic reaction, including anaphylaxis, since both drugs are in the same class.

C. Discuss the prescription with the health care provider: Amoxicillin is a penicillin derivative and contraindicated for clients with penicillin allergies. The nurse should immediately clarify the prescription with the provider before administration to ensure client safety.

D. Place an incident report in the medical record: Incident reports are used after an error or near-miss has occurred, not before a potential error is prevented. They are also never placed in the client’s medical record.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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.