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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

as evidenced by the client's.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Rationale for Correct Options:

  • Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
  • Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

  • Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
  • Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
  • Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
  • Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.


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Related Questions

Correct Answer is A,C,E,B,D

Explanation

A. Assess the appearance of the wound first to determine its condition and document characteristics such as drainage, size, and tissue type before collecting the specimen.

B. Place the swab in the culture tube immediately after obtaining the specimen to prevent contamination and preserve the sample.
C. Cleanse the wound with 0.9% sodium chloride to remove surface contaminants, which helps ensure the culture reflects true pathogens within the wound bed.
D. Cover the wound with a sterile dressing to protect the area from external contamination and promote healing after the specimen has been collected.

E. Obtain the specimen from granulation tissue of the wound, avoiding pooled drainage or necrotic areas, to ensure the most accurate culture results.

Correct Answer is D

Explanation

A. Place the newborn in the prone position: The supine position is recommended for newborns to reduce the risk of sudden infant death syndrome (SIDS). Phototherapy does not change this guideline, and the baby should be placed on their back.
B. Offer glucose water after each feeding: Glucose water is not recommended as a supplement. Breast milk or formula provides sufficient nutrition and hydration. The focus should be on maintaining regular feedings to support bilirubin excretion.
C. Apply lotion to the newborn's exposed skin: Lotions and ointments should be avoided during phototherapy because they can cause skin irritation or even burns when exposed to the phototherapy lights.
D. Cover the newborn's eyes with a mask: The eyes must be protected during phototherapy to prevent retinal damage from the intense light exposure. A properly fitted eye mask should be used and checked regularly for correct placement.

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