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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 D

Explanation

A. Critical pathways have an unlimited timeframe for completion: Critical pathways are designed with specific timelines to standardize care and ensure timely achievement of outcomes, so they do not have unlimited timeframes.
B. Nurses should discontinue the critical pathway if variances occur: Variances are documented and addressed, not a reason to discontinue the pathway. They help track deviations and guide individualized care adjustments.
C. Nurses' notes are used to create the critical pathway: Critical pathways are developed from evidence-based guidelines and clinical expertise, not directly from nurses' notes, though documentation helps evaluate their effectiveness.
D. Critical pathways should reduce health care costs: By standardizing care, minimizing delays, and improving efficiency, critical pathways aim to reduce unnecessary interventions and overall health care costs.

Correct Answer is B

Explanation

A. Match the client’s blood type with the type and cross match specimen: Type and crossmatching are important for allogeneic transfusions, but in autologous transfusions, the focus is on ensuring the unit belongs to the client rather than compatibility testing.
B. Ensure that the client's identification band matches the number on the blood unit: Verifying the client’s ID band against the unique number on the autologous blood unit ensures the right blood is given to the right person, preventing serious transfusion errors.
C. Confirm the provider's prescription matches the number on the blood component: The provider’s order is important, but it does not confirm the identity of the recipient. Matching the blood unit to the client’s ID is more critical for safety.
D. Ask the client to state his blood type and the date of the blood donation: Relying on client self-report is unreliable, especially in high-stress settings. Identification should always be confirmed using objective, verifiable identifiers like wristbands and blood unit labels.

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