Exhibits
The client is at risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Rationale for Correct Choices:
Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.
Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.
Rationale for Incorrect Choices:
Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.
Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.
Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.
Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.
Correct Answer is B
Explanation
A. Weight loss: Nicotine withdrawal typically leads to increased appetite and potential weight gain rather than weight loss. The absence of nicotine alters metabolism and hunger signals, often causing individuals to consume more food, especially carbohydrates, as a substitute for smoking.
B. Insomnia: Disruptions in sleep patterns are a common symptom of nicotine withdrawal. Nicotine is a stimulant that affects neurotransmitters, and its sudden absence can cause difficulty falling asleep, frequent nighttime awakenings, and restless sleep. Sleep disturbances can persist for several weeks after smoking cessation.
C. Diarrhea: Nicotine withdrawal is more commonly linked to constipation rather than diarrhea. Nicotine stimulates gut motility, and when discontinued, bowel movements may slow down, leading to temporary constipation rather than increased bowel activity.
D. Diaphoresis: While withdrawal can trigger irritability and autonomic symptoms such as mild sweating, excessive sweating is not a primary sign. More common symptoms include mood swings, restlessness, headaches, increased cravings, and difficulty concentrating as the body adjusts to the absence of nicotine.
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