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 A
Explanation
Rationale:
A. Encourage cultural practices to be incorporated into their care: Respecting and incorporating a Muslim client’s cultural and religious practices promotes culturally competent and patient-centered care. This approach fosters trust, comfort, and cooperation between the client and healthcare team.
B. Incorporate hot and cold practices into the client's care: Hot and cold theory is typically associated with Hispanic, Asian, and Middle Eastern folk medicine traditions, but not all Muslim clients follow this practice. Care should be based on the client’s individual beliefs.
C. Acknowledge that the client may be cared for by a male provider: Many Muslim women prefer to be cared for by female providers due to religious and cultural values of modesty. The nurse should make reasonable efforts to accommodate this preference whenever possible.
D. Have the client remove any face coverings to obtain their history: Muslim women who wear a niqab or hijab may choose to keep their face covered for modesty. The nurse should not insist on removal unless necessary for identification or assessment, and even then, it should be done privately with sensitivity to religious beliefs.
Correct Answer is A
Explanation
Rationale:
A. Creatinine: Serum creatinine is a key indicator of renal function. Cyclosporine is nephrotoxic, so monitoring both BUN and creatinine helps detect early signs of kidney impairment or transplant rejection.
B. Alkaline phosphatase: This enzyme primarily reflects liver and bone activity, not renal function. It is not routinely used to evaluate kidney status.
C. Bilirubin: Bilirubin levels are used to assess liver function and hemolytic disorders, not kidney function.
D. Amylase: Amylase is an enzyme related to pancreatic function and used to diagnose pancreatitis, not renal impairment.
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.