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.
Blood pressure.
Respiratory rate.
Report of headache.
Gravida/parity.
Fetal activity.
Urine ketones.
Correct Answer : A,B,D,F
The correct answer is choice A, B, D, and F.
Choice A rationale:
The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.
Choice B rationale:
The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.
Choice C rationale:
The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.
Choice D rationale:
The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.
Choice E rationale:
The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.
Choice F rationale:
The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.
Choice G rationale:
The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.
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Related Questions
Correct Answer is D
Explanation
Explanation: Yellow patches in the mouth are an indication of oral candidiasis, also known as thrush, which is a fungal infection caused by Candida albicans. Oral candidiasis can cause symptoms such as pain, burning, redness, and difficulty swallowing in addition to yellow patches on the tongue, palate, cheeks, or throat. Hearing loss, night sweats, and
brittle nails are not manifestations of candida infection.
Correct Answer is C
Explanation
Choice A rationale:
Weight gain is a common side effect of many antipsychotic medications, including haloperidol. While it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use.
Choice B rationale:
Dry mouth is a common anticholinergic side effect of antipsychotic medications like haloperidol. Although it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms, such as parkinsonism, associated with haloperidol use.
Choice C rationale:
This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it may indicate the development of a serious neurological condition called tardive dyskinesia.
Choice D rationale:
Sedation is a common side effect of haloperidol and other antipsychotic medications. While it is important to monitor for sedation, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use, as described in choice C.
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