A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record.
Blood pressure
Urine ketones
Fetal activity
Respiratory rate
Report of headache
Urine protein
Gravida/parity
Correct Answer : A,C,E,F
Rationale:
A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.
B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.
C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.
D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.
E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).
F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.
G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.
B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.
C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.
D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.
Correct Answer is D
Explanation
Rationale:
A. Diabetes screening: Screening for diabetes is a form of secondary prevention, aimed at early identification and intervention to prevent disease progression in asymptomatic individuals.
B. Nutrition counseling: Nutrition counseling is a primary prevention strategy when used to promote health and prevent disease. It aims to reduce risk factors before illness occurs.
C. Family planning: Family planning falls under primary prevention as it involves proactive measures to prevent unintended pregnancies and support reproductive health.
D. Physical therapy: Physical therapy is a tertiary prevention measure focused on reducing the impact of an existing disease or injury. It helps restore function, prevent further disability, and improve quality of life in individuals with chronic or advanced conditions.
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