The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply

seizures

hypoglycemia

cervical insufficiency

heart failure

placental abruption

Answer and Explanation

Correct Answer : A,E

Rationale for Correct Choices

• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.

• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.

Rationale for Incorrect Choices

• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.

• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.

• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.

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Correct Answer is C

Explanation

Rationale:
A. Diminished breath sounds: Decreased breath sounds could indicate airway obstruction or respiratory compromise but are not a primary sign of hemorrhage following a tonsillectomy. They are more often associated with complications such as laryngospasm or mucus plugging rather than bleeding.

B. Increased drowsiness: Drowsiness in the postoperative period may result from the effects of anesthesia or pain medication. While important to monitor, it is not a specific indicator of hemorrhage unless accompanied by other symptoms like hypotension or tachycardia.

C. Frequent swallowing: Repeated swallowing is an early and classic sign of hemorrhage after tonsillectomy. Children often swallow blood draining down the throat instead of spitting it out, which can lead to blood loss and airway compromise if not promptly addressed.

D. Elevated pain level: Pain is expected after tonsil surgery and does not necessarily indicate bleeding. Although increasing pain should be assessed, it is not a reliable or specific sign of postoperative hemorrhage compared to frequent swallowing.

A. Provide a pacifier for nonnutritive sucking. B. Warm the formula in the microwave prior to administration. C. Change the gastrostomy tube every 3 days. D. Place the infant in a supine position after the feeding.

Correct Answer is A

Explanation

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.

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The nurse is continuing to care for the client. Exhibits Which of the following conditions is the client is at greatest risk for developing? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply