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. Sacrum: The sacrum is typically assessed for pressure injuries but is not the most reliable site for detecting cyanosis in clients with dark skin because of variable pigmentation.
B. Shoulders: The shoulders have significant pigmentation and are not ideal for assessing cyanosis in dark-skinned clients due to difficulty distinguishing color changes.
C. Area of trauma: Trauma sites may show redness or bruising unrelated to cyanosis, making them unreliable for assessing oxygenation status.
D. Palms of the hands: The palms have less melanin and are lighter in color, making them a better site to observe for cyanosis in clients with dark skin due to clearer visualization of bluish discoloration.
Correct Answer is C
Explanation
A. “Remain on bed rest for 24 hours following the procedure.”: Prolonged bed rest increases the risk of venous stasis and deep vein thrombosis, so this instruction does not promote circulation and is not recommended.
B. “Place a pillow under your knees while in bed.”: Elevating the knees can impede venous return and increase the risk of blood clots, so this practice is discouraged for circulation promotion.
C. “Participate in range-of-motion exercises.”: Performing range-of-motion exercises helps stimulate blood flow, reduce venous stasis, and promote circulation, which is essential during the postoperative period to prevent complications.
D. “Use an incentive spirometer every 4 hours.”: Using an incentive spirometer improves lung expansion and oxygenation but does not directly promote circulation in the extremities.
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