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The nurse is continuing to assist with the care of the client.

Select words from the choices below to fill in each blank in the following sentence.

The complications that the client is at greatest risk for developing are

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

  • Seizures: The client’s symptoms of severe hypertension, persistent headache, hyperreflexia, proteinuria, and low platelet count strongly indicate severe preeclampsia, a condition that can rapidly progress to eclampsia, where seizures occur. This is a critical obstetric emergency requiring immediate intervention to prevent maternal and fetal morbidity.
  • Hypoglycemia: The client’s blood glucose level is 85 mg/dL, which is within the normal range. There are no signs such as diaphoresis, confusion, or weakness that would suggest hypoglycemia, and this condition is unrelated to the client's primary diagnosis of severe preeclampsia.
  • Cervical insufficiency: Cervical insufficiency typically causes painless cervical dilation and is associated with second-trimester pregnancy losses. The client is at 31 weeks with no reported cervical changes, contractions, or painless dilation, making this complication unlikely in the current clinical scenario.
  • Placental abruption: Severe hypertension increases the risk of placental abruption due to damage to the placental blood vessels. Signs of decreased fetal movement and the high-risk profile of preeclampsia support the concern that abruption could occur, leading to serious maternal and fetal compromise.
  • Heart failure: Although the client has some edema, there are no other clinical signs such as dyspnea, crackles, or orthopnea that would suggest heart failure. The edema seen here is consistent with preeclampsia rather than decompensated cardiac function.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

  • Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
  • Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
  • Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
  • Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
  • Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
  • Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

  • Deep tendon patellar reflex: The client's deep tendon reflexes improved from being hyperreflexive at 4+ to normal at 2+ without clonus on Day 2. This is a positive sign because hyperreflexia increases seizure risk in preeclampsia, and normalization indicates stabilization of neurological irritability.
  • Blood pressure: Although still elevated, the blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg by Day 2. While not normal yet, the trend toward lower values represents improvement in controlling the severe hypertension associated with preeclampsia.
  • Heart rate: The client's heart rate increased slightly from 72/min to 90/min. While still within normal range, this change reflects a more responsive and stable cardiovascular status, and there are no signs of bradycardia or distress, supporting mild improvement.
  • Edema: The client continues to have +3 pitting edema bilaterally, with no reported reduction compared to the initial assessment. Persistent severe edema suggests that fluid balance issues from preeclampsia have not yet improved and still require active management.

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