A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?
Blood pressure (BP) increase to 138/86 mm Hg.
Pitting pedal edema at the end of the day.
Weight gain of 0.5 kg during the past 2 weeks.
A dipstick value of 3+ for protein in her urine.
The Correct Answer is D
Choice A reason: A blood pressure increase to 138/86 mm Hg is not a concerning finding for preeclampsia. The diagnostic criteria for preeclampsia include a BP of 140/90 mm Hg or higher on two occasions at least 4 hours apart, or a BP of 160/110 mm Hg or higher on one occasion.
Choice B reason: Pitting pedal edema at the end of the day is not a concerning finding for preeclampsia. Edema is a common symptom of pregnancy and can be influenced by factors such as hydration, activity, and posture. Edema is not a reliable indicator of preeclampsia.
Choice C reason: Weight gain of 0.5 kg during the past 2 weeks is not a concerning finding for preeclampsia. The recommended weight gain for a normal-weight woman during pregnancy is 11.5 to 16 kg, with an average of 0.4 kg per week in the second and third trimesters.
Choice D reason: A dipstick value of 3+ for protein in her urine is a concerning finding for preeclampsia. Proteinuria is one of the hallmark signs of preeclampsia and indicates renal impairment. A dipstick value of 3+ corresponds to a protein concentration of 300 mg/dL or higher, which is considered severe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct action, as the rate is not within normal limits. A normal FHR at 30 weeks of gestation is between 110 and 160 beats/min. A rate of 82 beats/min is considered bradycardia (slow heart rate), which can indicate fetal distress or hypoxia (low oxygen).
Choice B reason: This is not the first action, but it may be necessary after confirming the FHR. The nurse should first rule out the possibility of a maternal-fetal heart rate confusion, which can occur when the maternal heart rate is mistakenly counted as the FHR. This can happen if the Doppler or the electronic fetal monitor is placed too close to the maternal pulse or if the maternal heart rate is unusually slow².
Choice C reason: This is the correct action, as it can help differentiate between the maternal and the fetal heart rate. The nurse should assess the woman's radial pulse at the same time as listening to the FHR and compare the rates and rhythms. If the rates are the same or very close, it is likely that the nurse is hearing the maternal heart rate instead of the FHR. If the rates are different, it is likely that the nurse is hearing the FHR and that the fetus has bradycardia.
Choice D reason: This is not the correct action, as it may cause unnecessary anxiety or distress for the woman. The nurse should not allow the woman to hear the heartbeat until the FHR is confirmed and the cause of the bradycardia is determined. The nurse should also explain the situation to the woman and provide reassurance and support.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Abstinence is the avoidance of sexual activity, which reduces the risk of exposure to STIs. It is not a sexual risk behavior.
Choice B reason: Multiple sex partners increases the likelihood of exposure to STIs, especially if the partners are not tested or treated. It is a sexual risk behavior.
Choice C reason: Unprotected anal intercourse exposes the mucous membranes of the rectum and anus to potential pathogens, which can cause STIs such as gonorrhea, chlamydia, syphilis, and HIV. It is a sexual risk behavior.
Choice D reason: Oral sex involves contact between the mouth and the genitals or anus, which can transmit STIs such as herpes, HPV, gonorrhea, and syphilis. It is a sexual risk behavior.
Choice E reason: Dry kissing is the contact between the lips without the exchange of saliva, which does not transmit STIs. It is not a sexual risk behavior.
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