The nurse is educating a first-time pregnant woman about preeclampsia.
Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Chills and fever.

Lack of appetite.

Swollen hands.

Headache.

Blurred vision.

Frequent urination.

Answer and Explanation

Correct Answer : C,D,E

Choice A rationale
Chills and fever are not typically associated with preeclampsia. They are more commonly seen in infections.
Choice B rationale
Lack of appetite is a non-specific symptom and can be associated with many conditions, but it is not a key indicator of preeclampsia.
Choice C rationale
Swollen hands can be a symptom of preeclampsia. This condition can cause sudden weight gain and swelling (edema), particularly in your face and hands.

Choice D rationale
Headaches are a common symptom of preeclampsia. They are often severe and may be accompanied by changes in vision.
Choice E rationale
Blurred vision is a symptom of preeclampsia. Other vision changes, such as sensitivity to light or temporary loss of vision, can also occur.
Choice F rationale
Frequent urination is not typically associated with preeclampsia. It is a common symptom in early and late pregnancy due to the growing uterus pressing on the bladder.

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Correct Answer is A

Explanation

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

A. Ignore the behavior and proceed with the IV antibiotic administration. B. Instruct the patient to cease the inappropriate behavior. C. Exit the room and close the door quietly. D. Fill out an unusual occurrence report.

Correct Answer is C

Explanation

Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.

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The nurse is educating a first-time pregnant woman about preeclampsia. Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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The nurse is educating a first-time pregnant woman about preeclampsia.
Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.