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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":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B,C"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

  • Hypoxia: Hypoxia is a key feature of epiglottitis due to airway obstruction from supraglottic swelling. It also occurs in RSV, where inflammation and mucus obstruct small airways, reducing oxygen exchange. Both conditions can require supplemental oxygen and prompt respiratory support.
  • Tachypnea: Increased respiratory rate is a compensatory mechanism for hypoxia and respiratory distress. In epiglottitis, it results from airway narrowing, while in RSV, it's due to bronchiolar inflammation, mucosal edema, and increased airway resistance.
  • Fever: Fever is a nonspecific but consistent sign in all three conditions. In epiglottitis, it’s often high-grade and abrupt. In RSV, it tends to be low to moderate. In streptococcal pharyngitis, fever accompanies tonsillar inflammation and systemic infection.
  • Exudate on pharynx: Purulent or white exudate on swollen tonsils is a hallmark of streptococcal pharyngitis, reflecting bacterial colonization and immune response. This finding is not typically seen in viral causes like RSV or in epiglottitis.
  • Drooling: Drooling is classic for epiglottitis due to pain and difficulty swallowing. The inflamed, swollen epiglottis causes discomfort and obstruction, preventing normal handling of oral secretions. It's a red flag for impending airway compromise.
  • Wheezing upon auscultation: RSV causes bronchiolitis, which leads to wheezing due to lower airway obstruction by mucus and inflammation. Wheezing is not a feature of epiglottitis (which affects the upper airway) or streptococcal pharyngitis (which affects the oropharynx).

Correct Answer is A

Explanation

A. Discuss the client's food preferences with the hospital's dietitian: Collaborating with the dietitian allows for personalization of the prescribed diet while maintaining its nutritional and therapeutic goals. This approach respects the client’s preferences and promotes adherence to the diabetes management plan.
B. Allow the client's family to bring food from home for the client: While family involvement is valuable, food from home may not comply with dietary restrictions and could interfere with blood glucose control unless reviewed by a dietitian or provider.
C. Request the provider change the client's prescribed diet: The issue is not the suitability of the prescribed diet but rather the client’s acceptance of it. Changing the prescription without first exploring preferences is premature.
D. Offer the client's meals on a different schedule: Changing meal timing alone does not address the client’s refusal to eat. Understanding and integrating food preferences is more effective in encouraging intake and supporting glycemic control.

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