The nurse is continuing to care for the client.
seizures
hypoglycemia
cervical insufficiency
heart failure
placental abruption
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "Avoid sexual intercourse for 7 days after receiving treatment.": HPV infections often persist in epithelial tissue even after visible lesions are treated, meaning transmission can still occur. Avoiding sexual contact for only 7 days does not eliminate the risk of spreading the virus.
B. "Obtain all recommended immunizations.": Receiving the HPV vaccine is the most effective method of preventing sexual transmission. The vaccine protects against high-risk HPV strains associated with cervical, anal, and oropharyngeal cancers, as well as genital warts. It is most effective when administered before sexual activity begins.
C. "Apply imiquimod ointment to any perineal ulcers.": Imiquimod is used to treat external genital warts caused by HPV, not perineal ulcers. Its use does not prevent infection or transmission and should only be applied to intact wart tissue under provider supervision.
D. "Undergo laser therapy to remove any lesions.": Laser therapy can remove visible warts but does not eradicate the virus itself. While it reduces the number of infectious lesions, HPV can still be transmitted through microscopic viral shedding even after lesion removal.
Correct Answer is A
Explanation
Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.
B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.
C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.
D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.
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