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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 {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

• Compartment syndrome: Occurs when pressure within a closed muscle compartment compromises circulation and tissue function. The client presents with classic signs: pain out of proportion, pallor (cool foot), pulselessness (non-palpable pulses), paresthesia (numbness), and paralysis (inability to move foot/toes) which are hallmark signs of compromised perfusion.

  • Osteomyelitis: The presence of drainage from the splint site, increasing temperature, and markedly elevated WBC count (from 14,000 to 28,000/mm³) strongly suggest developing bone infection. The client’s open fracture and internal fixation increase susceptibility, especially with new signs of systemic infection and localized inflammation at the injury site.

Rationale for Incorrect Choices:

• Deep vein thrombosis (DVT): While trauma and immobility increase DVT risk, there is no evidence of unilateral leg swelling, calf tenderness, or redness. The primary concern here is neurovascular compromise, not venous thromboembolism, and the symptoms point more urgently to compartment syndrome and infection.

• Fat embolism syndrome: Fat embolism is a risk with long bone fractures, typically presenting within 24–72 hours with respiratory distress, hypoxia, confusion, and a petechial rash. This client is alert and not in respiratory distress, with normal oxygen saturations and no mental status changes, making fat embolism less likely at this stage.

Correct Answer is A

Explanation

A. Footboard: A footboard helps maintain the foot in dorsiflexion and prevents it from pointing downward, which is essential in avoiding plantar flexion contractures in clients with limited mobility due to spinal cord injury.
B. Sheepskin heel pad: While this device helps reduce pressure and prevent skin breakdown on the heels, it does not provide structural support to keep the foot in the correct position and therefore does not prevent contractures.
C. Trochanter roll: A trochanter roll is placed alongside the outer thigh to prevent external rotation of the hip, not to support the foot or ankle. It is unrelated to plantar flexion prevention.
D. Abduction pillow: This is used to maintain proper hip alignment, especially after hip surgery. It does not provide support or positioning for the feet and is not effective for preventing foot contractures.

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