The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?
Seizures.
Stroke.
Organ damage.
Preterm birth.
Correct Answer : A,B,C,D
Choice A rationale
Seizures can occur due to severe preeclampsia, leading to eclampsia, characterized by generalized tonic-clonic seizures. Magnesium sulfate is often used to prevent seizures in these patients, alongside other monitoring measures.
Choice B rationale
Stroke risk is elevated in preeclamptic patients due to hypertension, endothelial dysfunction, and increased coagulation. Blood pressure control is essential to reduce stroke risk and manage preeclampsia complications effectively.
Choice C rationale
Organ damage, particularly to the liver and kidneys, is a complication of preeclampsia. Elevated liver enzymes and proteinuria indicate hepatic and renal involvement, necessitating close monitoring and potential intervention to mitigate damage.
Choice D rationale
Preterm birth is often a result of preeclampsia due to placental insufficiency and maternal health deterioration. Early delivery may be necessary to protect the well-being of both mother and fetus, highlighting the importance of timely diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Shallow and irregular respirations are normal for newborns and do not typically indicate respiratory distress. Regular assessment is necessary to determine if there is an underlying issue.
Choice B rationale
Flaring of the nares is a sign of increased effort to breathe and is an indication of respiratory distress in newborns. This symptom requires immediate attention to address potential underlying conditions.
Choice C rationale
Abdominal breathing with synchronous chest movement is normal in newborns due to their diaphragmatic breathing pattern. It does not indicate respiratory distress unless other symptoms are present.
Choice D rationale
A respiratory rate of 50 breaths per minute is within the normal range for newborns (30-60 breaths per minute). This does not indicate respiratory distress unless accompanied by other abnormal signs.
Correct Answer is A
Explanation
Choice A rationale
A heel stick blood glucose test is crucial for an infant showing jitteriness, hypotonicity, and weak cry as these symptoms suggest hypoglycemia which requires immediate confirmation and treatment.
Choice B rationale
Documenting findings is essential but does not address the immediate need to rule out and treat hypoglycemia in the symptomatic newborn.
Choice C rationale
Swaddling the infant provides comfort and warmth but does not address potential hypoglycemia, which is the priority in this case.
Choice D rationale
Placing a pulse oximeter monitors oxygenation but does not directly address the underlying cause of jitteriness and hypotonia, which could be hypoglycemia.
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