The nurse is continuing to care for the client.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Rationale for Correct Choices:
- Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
- Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.
Rationale for Incorrect Choices:
- Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
- Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
- Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Acetaminophen: Acetaminophen is generally considered safe during pregnancy when used at recommended doses. It is commonly used to treat mild pain and fever without significant risk to the fetus.
B. Saline nasal spray: Saline nasal sprays are non-medicated and safe for use during pregnancy. They help relieve nasal congestion without systemic absorption or risk to fetal development.
C. Levothyroxine: Levothyroxine is a thyroid hormone replacement that is safe and essential during pregnancy for clients with hypothyroidism. Untreated hypothyroidism poses greater risks to both mother and fetus than the medication itself.
D. Ibuprofen: Ibuprofen is contraindicated, especially during the third trimester, due to risks such as premature closure of the ductus arteriosus, oligohydramnios, and delayed labor. Acetaminophen is preferred for pain relief in pregnancy.
Correct Answer is C
Explanation
Rationale:
A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.
B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.
C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.
D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.
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