The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Swollen hands.

Headache.

Blurred vision.

Lack of appetite.

Chills and fever.

Urinary frequency.

Answer and Explanation

Correct Answer : A,B,C

A. Swollen hands can indicate edema, which is a common sign of preeclampsia. Swelling, especially in the hands, face, or feet, can be due to elevated blood pressure and should be reported to the healthcare provider.

B. Headaches are a concerning symptom in preeclampsia, especially when they are persistent or severe. This is often due to high blood pressure and requires medical evaluation to prevent complications like eclampsia or stroke.

C. Blurred vision is a serious indicator of preeclampsia as it reflects possible neurological involvement or increased blood pressure, which can affect blood flow to the brain and eyes. This is an urgent symptom that needs prompt medical attention.

D. Lack of appetite is not a common or specific symptom of preeclampsia. It may be present in other conditions, but it is not a key indicator of preeclampsia.

E. Chills and fever are typically associated with infections, not preeclampsia. These symptoms do not indicate the presence of preeclampsia and are unrelated to hypertensive disorders of pregnancy.

F. Urinary frequency is more commonly related to pregnancy in general due to the growing uterus pressing on the bladder. It is not specifically associated with preeclampsia. In preeclampsia, a decrease in urine output may be more concerning as it can signal kidney involvement.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

Correct Answer is ["0.8"]

Explanation

Convert the client's weight from pounds to kilograms (kg).
Calculate the enoxaparin sodium dosage per day based on the client's weight and the prescribed dosage of 1.5 mg/kg/day.
Divide the enoxaparin sodium dosage by the concentration of the medication in the prefilled syringe (120 mg/0.8 mL) to determine the volume to administer.

Step 1: Convert weight from pounds to kilograms

- Client's weight in kg = Client's weight in pounds / 2.2
- Client's weight in kg = 176 pounds / 2.2 = 80 kg

Step 2: Calculate enoxaparin sodium dosage per day

- Enoxaparin sodium dosage (mg/day) = Client's weight (kg) × Prescribed dosage (mg/kg/day)
- Enoxaparin sodium dosage (mg/day) = 80 kg × 1.5 mg/kg/day = 120 mg/day

Step 3: Determine the volume to administer

- Volume to administer (mL) = Enoxaparin sodium dosage (mg/day) / Medication concentration (mg/mL)
- Volume to administer (mL) = 120 mg/day / (120 mg/0.8 mL) = 0.8 mL

Therefore, the nurse should administer 0.8 mL of enoxaparin sodium to the client.

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The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Correct Answer is A

Explanation

A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5mg/kg/day subcutaneously. The medication is available in 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

Correct Answer is ["0.8"]

Explanation

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