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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

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.

Correct Answer is D

Explanation

A. "The client was intubated without complications.": While relevant to the surgical process, this detail is more critical in the operating or PACU setting and less essential for ongoing post-op care unless complications occurred.
B. "The client is a member of the board of directors.": This is not clinically relevant and violates the client’s confidentiality by sharing unnecessary personal information.
C. "There was a total of 10 sponges used during the procedure.": Sponge count is important intraoperatively, but it is not typically necessary in a hand-off unless a count discrepancy occurred.
D. "The estimated blood loss was 250 milliliters.": This is clinically relevant and necessary for postoperative monitoring. It informs the receiving nurse about potential volume loss and the need to monitor for signs of hypovolemia.

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