A nurse is collecting data from a client who is at 29 weeks of gestation.
Which of the following findings should the nurse identify as a potential indication of a prenatal complication?
Leg cramps.
Ptyalism.
Blurred vision.
Melasma.
The Correct Answer is C
This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.
The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.
Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.
Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.
Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.
Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.
Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.
Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.
Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.
Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.
Correct Answer is A
Explanation
Muscle irritability. A client with a lithium level of
2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.
Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.
Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.
Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.
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