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 C
Explanation
Step 1: Convert the dopamine hydrochloride dose from mcg to mg. We know that 1 mg = 1000 mcg. So, 4 mcg = 0.004 mg.
Step 2: Calculate the total amount of dopamine hydrochloride the client needs per minute. We know that the client weighs 80 kg and the dose is 0.004 mg/kg/min. So, 0.004 mg/kg/min × 80 kg = 0.32 mg/min.
Step 3: Convert the total amount of dopamine hydrochloride the client needs per minute to an hourly rate. We know that 1 hour = 60 minutes. So, 0.32 mg/min × 60 min/hr = 19.2 mg/hr.
Step 4: Calculate the volume of the solution that contains 19.2 mg of dopamine hydrochloride. We know that the solution contains 800 mg in 250 mL. So, (19.2 mg ÷ 800 mg) × 250 mL = 6 mL.
Therefore, the nurse should set the IV infusion to deliver 6 mL/hr (rounded to the nearest whole number).
Correct Answer is A
Explanation
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
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