The prenatal clinic nurse monitored women for preeclampsia. All four women were in the clinic at the same time. Which one should the nurse see first?
Weight gain of 0.5 kg during the past 2 weeks
Pitting pedal edema at the end of the day
Blood pressure increase to 138/86 mm Hg
Dipstick value of 3+ for protein in her urine
The Correct Answer is D
Choice A) Weight gain of 0.5 kg during the past 2 weeks: This is a normal weight gain for a pregnant woman and does not indicate preeclampsia.
Choice B) Pitting pedal edema at the end of the day: This is a common symptom of pregnancy and does not necessarily indicate preeclampsia. It can be relieved by elevating the legs and wearing compression stockings.
Choice C) Blood pressure increase to 138/86 mm Hg: This is a mild elevation of blood pressure and does not meet the criteria for preeclampsia, which is defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher on two occasions at least four hours apart.
Choice D) Dipstick value of 3+ for protein in her urine: This is a sign of significant proteinuria, which is one of the main features of preeclampsia. Proteinuria is defined as a urinary protein excretion of 300 mg or more in 24 hours or a dipstick reading of 1+ or higher. A dipstick value of 3+ indicates severe proteinuria and requires immediate attention and treatment. This woman has the highest risk of developing complications from preeclampsia, such as eclampsia, HELLP syndrome, placental abruption, or fetal growth restriction . Therefore, she should be seen by the nurse first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A) Obtain an oxygen saturation: This is not a priority action because it does not address the underlying cause of the respiratory distress, which is meconium aspiration. Meconium aspiration can cause airway obstruction, inflammation, infection, and pulmonary hypertension in the newborn. Oxygen saturation may be low, but it is not a reliable indicator of the severity of the condition.
Choice B) Stimulate the baby to increase respirations: This is not a priority action because it may worsen the respiratory distress by increasing the work of breathing and causing more meconium to be aspirated. Stimulation may also cause stress and hypoxia in the newborn.
Choice C) Prepare to initiate ECMO: This is not a priority action because it is a last resort treatment for severe cases of meconium aspiration syndrome that do not respond to conventional therapies. ECMO stands for extracorporeal membrane oxygenation, which is a form of life support that bypasses the lungs and provides oxygen to the blood.
ECMO has many risks and complications, such as bleeding, infection, and organ damage. It should only be used when other options have failed and with the consent of the parents.
Choice D) Notify the provider at once: This is the correct action because it allows for prompt assessment and intervention by the provider, who can initiate appropriate treatments for meconium aspiration syndrome. These may include suctioning of the airway, administration of antibiotics, surfactant, or inhaled nitric oxide, and mechanical ventilation . Early treatment can improve the outcomes and reduce the complications of meconium aspiration syndrome.
Correct Answer is C
Explanation
Choice a) Breasts firm and tender is incorrect because this is not a sign of normal involution, but rather a sign of breast engorgement, which is a common problem in the first few weeks of breastfeeding. Breast engorgement occurs when thE breasts become overfilled with milk, causing them to feel hard, swollen, painful, and warm. It can be prevented or relieved by frequent and effective breastfeeding, applying warm or cold compresses, massaging the breasts, expressing some milk, and wearing a supportive bra.
Choice b) Episiotomy slightly red and puffy is incorrect because this is not a sign of normal involution, but rather a sign of inflammation or infection of the perineal wound. An episiotomy is a surgical cut made in the perineum (the area between the vagina and the anus) to enlarge the vaginal opening during delivery. It can take several weeks to heal and may cause pain, swelling, bruising, bleeding, or discharge. It can be cared for by keeping the area clean and dry, applying ice packs or witch hazel pads, taking painkillers or sitz baths, and avoiding constipation or straining.
Choice c) Fundus below the symphysis and not palpable is correct because this is a sign of normal involution, which is the process of the uterus returning to its pre-pregnancy size and shape after delivery. The fundus is the upper part of the uterus that can be felt through the abdomen. Immediately after delivery, the fundus is about the size of a grapefruit and can be felt at or above the umbilicus (the navel). It gradually descends about one fingerbreadth per day until it reaches the level of the symphysis pubis (the joint where the two pubic bones meet) by about 10 days postpartum. By 14 days postpartum, the fundus should be below the symphysis and not palpable.
Choice d) Moderate bright red lochial flow is incorrect because this is not a sign of normal involution, but rather a sign of excessive or prolonged bleeding after delivery. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the lining of the uterus. It changes in color and amount over time, from red to pink to brown to yellow to white. The normal lochia flow should be scant to moderate in amount, dark red to brown in color, and last for about 4 to 6 weeks postpartum. A moderate bright red lochial flow on day 14 postpartum may indicate that the uterus is not contracting well or that there is an infection or retained placental tissue in the uterus.
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