The nurse is continuing to care for the client.
Nurses' Notes.
Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.
headache unrelieved by acetaminophen.
Client also reports.
urinary frequency and decreased fetal movement.
Client is a G3. P2 with one preterm birth.
Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.
+3. pitting edema in bilateral lower extremities.
Patellar reflex 4+. without the presence of clonus.
Client reports occasional.
nighttime leg cramps.
Reports three fetal movements within the.
last 30 min.
External fetal monitor applied with a baseline FHR.
140/min with occasional accelerations and moderate variability.
No uterine contractions noted.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Oxygen saturation 979% on room air.
Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 999% on room air.
Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). The nurse is reviewing the assessment findings.
For each assessment finding, click to specify if the finding is consistent with.
preeclampsia or HELLP syndrome.
Each finding may support more than one.
disease process.
Platelet count
Hemoglobin
Alanine aminotransferase (ALT)
Blood pressure
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Preparing to assist with intubation is the appropriate action for a nurse caring for a child with suspected epiglottitis. Epiglottitis is a medical emergency where the airway can become severely compromised due to inflammation of the epiglottis. Intubation ensures a secure airway, allowing the child to breathe and preventing respiratory distress.
Choice B rationale:
Preparing a cool mist tent is not the priority in suspected epiglottitis. While humidified air can provide comfort for respiratory distress, it does not address the potential for airway obstruction. Intubation takes precedence in this critical situation.
Choice C rationale:
Suctioning the child's oropharynx may worsen the condition in suspected epiglottitis. Suctioning can stimulate the epiglottis, triggering a spasm and further obstructing the airway. Intubation is the primary intervention to secure the airway safely.
Choice D rationale:
Obtaining a throat culture is not the immediate action in suspected epiglottitis. While a throat culture may confirm the diagnosis, the priority is securing the airway to prevent respiratory distress and hypoxia.
Correct Answer is A
Explanation
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