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.
Urine protein
Report of headache
Urine ketones
Fetal activity
Blood pressure
Correct Answer : A,B,D,E
A. Urine protein: The presence of 3+ protein in the urine is abnormal and indicates significant proteinuria, which is a key sign of preeclampsia. Monitoring protein levels is essential for detecting kidney involvement and assessing maternal and fetal risk.
B. Report of headache: A severe headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a concerning symptom of preeclampsia. It can indicate cerebral involvement and increased risk for complications such as eclampsia or stroke.
D. Fetal activity: Decreased fetal movement is an important sign of potential fetal compromise. Reduced activity may indicate fetal distress or hypoxia, requiring prompt assessment and possible intervention.
E. Blood pressure: A blood pressure reading of 162/112 mm Hg is significantly elevated and meets criteria for severe preeclampsia. Hypertension during pregnancy can lead to maternal and fetal complications, making this a critical finding to address immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Clean the insertion site with betadine: While povidone-iodine (Betadine) can be used, current guidelines recommend using chlorhexidine for central line site care because it is more effective in preventing catheter-related bloodstream infections. Using betadine is not the preferred standard of care.
B. Flush the catheter with sterile water: Central venous catheters should be flushed with sterile saline, not sterile water, to maintain patency and avoid hemolysis or electrolyte imbalance. Flushing with water can damage blood cells and the catheter.
C. Use a 5-mL syringe to flush the catheter: A minimum of a 10-mL syringe is recommended when flushing a central venous catheter because smaller syringes generate excessive pressure that can damage the catheter. Using a 5-mL syringe increases the risk of catheter rupture.
D. Wear sterile gloves when providing site care: Sterile technique is required when performing central line site care to prevent infection. Wearing sterile gloves protects the client from pathogens and is a critical step in maintaining asepsis during dressing changes and catheter maintenance.
Correct Answer is D
Explanation
A. "I have headaches in the evening.": Headaches associated with sleep apnea typically occur in the morning due to nocturnal hypoxia and carbon dioxide retention, not in the evening. Evening headaches are not a common presenting symptom.
B. "I feel rested upon wakening.": Clients with sleep apnea often experience non-restorative sleep and wake feeling tired or unrefreshed. Feeling rested upon waking would not be expected in untreated sleep apnea.
C. "I feel alert during the day.": Daytime sleepiness is a hallmark symptom of sleep apnea due to fragmented sleep and oxygen desaturation. Feeling alert would not align with the typical presentation.
D. "My spouse says I snore.": Loud, habitual snoring is a common and expected symptom of obstructive sleep apnea. It is often reported by bed partners and is an important clinical clue for diagnosis.
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