The nurse continues to care for the client who is at 30 weeks of gestation.
Complete the following sentence by using the lists of options.
The client is at highest risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in an upright or high-Fowler’s position to allow fluid to pool in the lower abdomen for easier access and drainage.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not routinely indicated for paracentesis since the bowel does not obstruct access to ascitic fluid, making this an unnecessary step.
C. Ensure the client has a full bladder just prior to the procedure: A full bladder increases the risk of accidental puncture during needle insertion. The bladder should be emptied to reduce this risk.
D. Weigh the client before and after the procedure: Weighing the client allows the healthcare team to estimate the volume of ascitic fluid removed and assess fluid balance, making this a key nursing responsibility.
Correct Answer is A
Explanation
A. Bradypnea: Magnesium sulfate toxicity depresses the central nervous system, leading to respiratory depression such as bradypnea. This is a critical sign requiring immediate intervention, as respiratory rates below 12 breaths per minute can be life-threatening.
B. Tremors: Tremors are typically associated with hypomagnesemia or withdrawal states, not magnesium toxicity. Magnesium toxicity causes muscle weakness and diminished reflexes rather than increased neuromuscular activity.
C. Insomnia: Insomnia is not a recognized symptom of magnesium toxicity. In contrast, elevated magnesium levels tend to cause sedation, lethargy, and decreased mental alertness.
D. Hypertension: Magnesium sulfate can actually lower blood pressure due to its vasodilatory effects. Hypertension would be inconsistent with toxicity and more commonly seen in preeclampsia before magnesium is administered.
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