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 A
Explanation
Rationale:
A. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.
B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.
C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.
D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.
Correct Answer is B
Explanation
Rationale:
A. Increased platelet count: Preeclampsia is often associated with thrombocytopenia (low platelet count), not an increase. A falling platelet count can be a warning sign of worsening disease or progression to HELLP syndrome.
B. Increased protein in urine: Proteinuria is one of the hallmark signs of preeclampsia, resulting from glomerular damage in the kidneys. A 24-hour urine protein test or dipstick is commonly used to detect elevated protein levels during pregnancy.
C. Decreased BUN: Blood urea nitrogen (BUN) may increase if renal perfusion is compromised, but a decrease is not typical in preeclampsia. Kidney involvement often leads to elevated BUN and creatinine levels.
D. Decreased serum uric acid: Preeclampsia usually causes elevated serum uric acid levels due to decreased renal clearance. A drop in uric acid would be inconsistent with this diagnosis
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