A nurse is teaching a client with mild pre-eclampsia about the signs and symptoms that she should report to the health care provider.
Which of the following should the nurse include? (Select all that apply)
Sudden weight gain
Decreased fetal movement
Vaginal bleeding
Nausea and vomiting
Swelling of the hands and feet
Correct Answer : A,B
The correct answer is choice A and B. Sudden weight gain and decreased fetal movement are signs of pre-eclampsia, a condition that develops in pregnant women and is marked by high blood pressure and presence of proteins in urine. Pre-eclampsia can affect the blood supply to the placenta and the growth of the baby.
Choice C is wrong because vaginal bleeding is not a symptom of pre-eclampsia, but it may indicate other problems such as placental abruption or miscarriage.
Choice D is wrong because nausea and vomiting are not specific symptoms of pre-eclampsia, but they may occur in some cases. However, excessive vomiting and nausea may be a sign of severe pre-eclampsia.
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Correct Answer is B
Explanation
Decreased fibrinogen level.This indicates that the client has a risk of disseminated intravascular coagulation (DIC), which is a condition where the blood clots abnormally and causes bleeding in various organs.Fibrinogen is a protein that is essential for blood clotting, and a low level means that the clotting factors are being consumed faster than they can be produced.
Choice A is wrong because elevated platelet count is not a sign of DIC, but rather of normal pregnancy or other conditions that cause thrombocytosis.Platelets are blood cells that help form clots, and a high count means that there is an increased production or decreased destruction of platelets.
Choice C is wrong because increased prothrombin time (PT) is not a specific sign of DIC, but rather of any condition that affects the extrinsic pathway of coagulation.PT measures how long it takes for the blood to clot by adding tissue factor, which activates factor VII.A prolonged PT means that there is a deficiency or dysfunction of factor VII or other factors in the common pathway (X, V, II, I).
Choice D is wrong because reduced partial thromboplastin time (PTT) is not a sign of DIC, but rather of hypercoagulable states or antiphospholipid syndrome.PTT measures how long it takes for the blood to clot by adding phospholipids and an activator, which activate factor XII.A shortened PTT means that there is an increased activity or presence of factor XII or other factors in the intrinsic or common pathway.
Correct Answer is D
Explanation
To prevent blood pressure from exceeding 160/110 mmHg.The goal of pharmacological therapy for pre-eclampsia is to prevent severe hypertension that can lead to complications such as stroke, kidney failure, or placental abruption.
Choice A is wrong because maintaining blood pressure below 140/90 mmHg is the target for normal hypertension, not pre-eclampsia.
Choice B is wrong because reducing blood pressure by 25% within one hour is too rapid and can compromise blood flow to the placenta and the fetus.
Choice C is wrong because keeping diastolic blood pressure between 80 and 100 mmHg is not specific enough and does not account for the systolic blood pressure, which is also important.
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