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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 B

Explanation

A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that magnesium levels are not excessively high. Diminished or absent reflexes would be a more concerning sign of toxicity.
B. Respiratory rate 10/min: A respiratory rate below 12/min suggests respiratory depression, which is a serious adverse effect of magnesium sulfate toxicity. This is the priority finding requiring immediate intervention.
C. Urinary output 35 mL/hr: This is slightly above the minimum expected output of 30 mL/hr. While renal function must be monitored to prevent magnesium accumulation, this rate is adequate for now.
D. Pedal edema: Edema is common in preeclampsia and is not an urgent concern compared to signs of magnesium toxicity such as respiratory depression.

Correct Answer is D

Explanation

A. Fill out an incident report: While documentation is essential for quality improvement and accountability, it is not the immediate priority. The client’s safety must be addressed before any administrative action is taken.
B. Report the incident to the nurse manager: Notifying the manager is an important step in the reporting chain, but it should occur after ensuring the client is stable and receiving appropriate clinical care.
C. Notify the provider: The provider must be informed to assess for possible interventions or antidotes, but the nurse should first collect the client’s current clinical status to report meaningful information.
D. Measure the client's vital signs: Assessing the client’s condition is the first priority after a medication error. Vital signs provide critical information on the client’s immediate response and help guide the next steps in managing the error.

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