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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.

Urine protein.

Blood pressure.

Respiratory rate.

Report of headache.

Gravida/parity.

Fetal activity.

Urine ketones.

Answer and Explanation

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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Correct Answer is B

Explanation

The correct answer is choice B: Axillary.

Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.

Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.

Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.

Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.

A. "This type of seizure lasts 30 to 60 seconds." B. "This type of seizure can be mistaken for daydreaming." C. "The child usually has an aura prior to onset." D. "This type of seizure has a gradual onset." .

Correct Answer is B

Explanation

Choice A rationale:

Absence seizures typically last for a few seconds, not 30 to 60 seconds. This choice is incorrect because it provides inaccurate information about the duration of absence seizures.

Choice B rationale:

Absence seizures are brief episodes of staring that can be mistaken for daydreaming. It is crucial for the parent to recognize this symptom to ensure the child's safety and seek appropriate medical attention if needed.

Choice C rationale:

Absence seizures usually occur without warning or an aura. There is no specific warning sign before the onset of absence seizures, making this choice incorrect.

Choice D rationale:

Absence seizures have a sudden onset and offset without any warning signs, so they do not have a gradual onset. This information is incorrect regarding absence seizures.

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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.

Nursing Test Bank

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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.