A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?
Dipstick value of 3+ for protein in her urine
Pitting pedal edema at the end of the day
Weight gain of 0.5 kg during the past 2 weeks
Blood pressure (BP) increase to 138/86 mm Hg
The Correct Answer is A
Choice A reason: Dipstick value of 3+ for protein in her urine is a sign of significant proteinuria, which is one of the diagnostic criteria for preeclampsia, along with hypertension. Proteinuria indicates renal damage and impaired glomerular filtration, which can lead to complications, such as oliguria, eclampsia, or HELLP syndrome.
Choice B reason: Pitting pedal edema at the end of the day is a common and expected finding in pregnancy, as it results from the increased blood volume, venous pressure, and fluid retention. Edema is not a reliable indicator of preeclampsia, unless it is severe, generalized, or sudden.
Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is a normal and expected finding in pregnancy, as it reflects the growth and development of the fetus, placenta, and maternal tissues. Weight gain is not a reliable indicator of preeclampsia, unless it is excessive, rapid, or associated with edema.
Choice D reason: Blood pressure (BP) increase to 138/86 mm Hg is a mild elevation that may indicate gestational hypertension, but not preeclampsia, unless it is accompanied by proteinuria or other signs of organ dysfunction. The diagnostic threshold for preeclampsia is a BP of 140/90 mm Hg or higher on two occasions at least four hours apart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To calculate the number of tablets, the nurse should use the following formula:
Number of tablets = (Desired dose / Available dose) x (Available form / Desired form)
In this case, the desired dose is 50 mg, the available dose is 100 mg, the available form is 1 tablet, and the desired form is 1 tablet. Therefore, the formula becomes:
Number of tablets = (50 mg / 100 mg) x (1 tablet / 1 tablet)
Number of tablets = 0.5 x 1
Number of tablets = 0.5
The nurse should round the answer to the nearest tenth, which is 0.5. The nurse should use a leading zero if the answer is less than 1, which is 0.5. The nurse should not use a trailing zero, which means 0.5 and not 0.50.
Correct Answer is C
Explanation
Choice A reason: A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions does not need to be reported to the provider immediately, because it may indicate preterm labor, which is not an emergency. The nurse should assess the client's cervix, fetal heart rate, and hydration status, and administer tocolytic therapy as prescribed.
Choice B reason: A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes does not need to be reported to the provider immediately, because they are expected findings in mild preeclampsia. The nurse should monitor the client's blood pressure, urine output, and reflexes, and administer antihypertensive and anticonvulsant medications as prescribed.
Choice C reason: A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache needs to be reported to the provider immediately, because they are signs of severe preeclampsia or impending eclampsia. The nurse should prepare the client for delivery, as it is the only definitive treatment for preeclampsia.
Choice D reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors does not need to be reported to the provider immediately, because they are a common and mild side effect of terbutaline, a beta-adrenergic agonist that relaxes the uterine smooth muscle. The nurse should reassure the client that the tremors are temporary and harmless, and monitor the client's pulse and blood pressure.
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