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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
Choice B rationale:
Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling
Choice C rationale:
Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort
Choice D rationale:
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
Correct Answer is C
Explanation
Choice A rationale: Hypoglycemia refers to low blood sugar levels. This condition can occur in newborns, especially those born to mothers with diabetes, preterm babies, babies who are small for gestational age, or those who have experienced a difficult delivery. However, the provided information does not indicate any signs of hypoglycemia such as jitteriness, poor feeding, or lethargy.
Choice B rationale: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that affects newborns and infants. It’s more common in premature infants who have received oxygen therapy or mechanical ventilation. The newborn’s information does not suggest any risk factors for BPD.
Choice C rationale: Transient tachypnea of the newborn (TTN) is a respiratory problem that can be seen shortly after delivery in babies who have no other health issues. It’s caused by fluid in the lungs. The newborn’s increased respiratory rate and grunting are signs of TTN. This condition is more common in babies delivered via cesarean birth, as in this case.
Choice D rationale: Tachycardia refers to a heart rate that’s too fast. While the newborn’s heart rate is on the higher side of normal (normal range: 120-160 beats per minute), it’s not high enough to be considered tachycardia. Therefore, based on the provided information, the newborn is at risk for developing Transient tachypnea of the newborn (Choice C). The other conditions mentioned do not align with the symptoms and risk factors presented in the scenario.
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