The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Edema.

BP 155/92.

Proteinuria.

Hepatic dysfunction.

BP returns to normal after pregnancy.

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

Edema is not an expected finding of uncomplicated gestational hypertension. While some degree of edema can be common during pregnancy, it is not specifically related to gestational hypertension.

Choice B rationale:

A blood pressure reading of 155/92 is an expected finding in a client with uncomplicated gestational hypertension. Gestational hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg after 20 weeks of pregnancy, without the presence of proteinuria or other organ dysfunction.

Choice C rationale:

Proteinuria is an expected finding in gestational hypertension. It is an important diagnostic criterion for preeclampsia, which is a severe form of gestational hypertension.

Choice D rationale:

Hepatic dysfunction is not an expected finding in uncomplicated gestational hypertension. Hepatic dysfunction would indicate more severe complications such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count), which is a medical emergency.

Choice E rationale:

Blood pressure usually returns to normal after pregnancy in women with uncomplicated gestational hypertension. However, it is essential to monitor the client closely postpartum to ensure blood pressure normalization.

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Correct Answer is C

Explanation

Choice A rationale:

Increasing potassium intake is not specifically associated with relieving breast discomfort during menstruation. There is no established link between potassium intake and fibrocystic breast changes.

Choice B rationale:

Increasing fluid intake is generally beneficial for overall health, but it is not a specific recommendation for managing breast discomfort during menstruation. It may not have a direct impact on fibrocystic breast changes.

Choice C rationale:

Decreasing sodium intake before menstruation is a relevant instruction for managing breast discomfort associated with fibrocystic breast changes. High sodium intake can lead to water retention and breast swelling, exacerbating discomfort.

Choice D rationale:

Daily fiber intake is important for bowel health but is not directly related to managing breast discomfort during menstruation or fibrocystic breast changes.

A. Assist the client to void every 3 hr. B. Monitor contractions every 30 min. C. Place the client into a lithotomy position. D. Encourage the client to use a pant-blow breathing pattern.

Correct Answer is D

Explanation

Choice D rationale:

During the transition phase of labor, the nurse should encourage the client to use a pant- blow breathing pattern. The transition phase is intense, and pant-blow breathing (a form of controlled breathing) can help the client manage the pain and reduce anxiety. Panting during contractions allows the client to focus on short, shallow breaths, which can be more effective than deep breathing during this stage.

Choice A rationale:

Assisting the client to void every 3 hours is important during labor, but it is not specific to the transition phase. The nurse should encourage the client to void regularly during the entire labor process to prevent bladder distension and facilitate the descent of the baby. However, during the transition phase, the client may be more focused on contractions and may not need reminders to void every 3 hours.

Choice B rationale:

Monitoring contractions every 30 minutes is not appropriate during the transition phase of labor. The transition phase is characterized by frequent and strong contractions, and continuous monitoring of contractions is usually required during this phase to ensure fetal well-being and progress in labor.

Choice C rationale:

Placing the client into a lithotomy position is not appropriate during the transition phase of labor. The lithotomy position, where the client lies on their back with legs raised and supported in stirrups, is often used during the pushing phase. During the transition phase, it is more common for the client to be in an upright or semi-reclining position to facilitate the descent of the baby through the birth canal.

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The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?

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