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 C
Explanation
Choice a) D5W intravenously is incorrect because this is not the preferred method of feeding for a hypoglycemic infant. D5W stands for dextrose 5% in water, which is a solution that contains glucose and water. It can be used to treat hypoglycemia by providing a source of energy and fluid to the infant. However, it has several disadvantages, such as requiring an invasive procedure, increasing the risk of infection, causing fluid overload or electrolyte imbalance, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, D5W intravenously should be reserved for severe cases of hypoglycemia that do not respond to oral or enteral feeding.
Choice b) Formula via nasogastric tube is incorrect because this is not the first-line option of feeding for a hypoglycemic infant. Formula is an artificial substitute for breast milk that contains nutrients and calories to support the infant's growth and development. It can be given via nasogastric tube, which is a tube that passes through the nose and into the stomach, when the infant cannot suck or swallow effectively. However, formula has several disadvantages, such as being less digestible, less immunogenic, and less adaptable than breast milk, as well as increasing the risk of necrotizing enterocolitis, allergy, or infection. Therefore, formula via nasogastric tube should be used only when breast milk is unavailable or contraindicated.
Choice c) Breast milk is correct because this is the best and most recommended type of feeding for a hypoglycemic infant. Breast milk is the natural and optimal food for infants that contains all the nutrients and antibodies they need to grow and thrive. It can be given directly from the breast or expressed and fed by bottle or cup. Breast milk has several advantages, such as being easily digestible, enhancing immune function, promoting bonding, and adjusting to the infant's needs. Breast milk also contains lactose, which is a natural sugar that can raise the blood glucose level of the infant without causing a spike in insulin secretion. Therefore, breast milk should be offered to the hypoglycemic infant as soon as possible after birth and at regular intervals thereafter.
Choice d) Glucose water in a bottle is incorrect because this is not an appropriate type of feeding for a hypoglycemic infant. Glucose water is a solution that contains glucose and water. It can be given by bottle or cup to provide a quick source of energy to the infant. However, it has several disadvantages, such as providing no other nutrients or calories, interfering with breastfeeding, causing diarrhea or dehydration, and stimulating insulin secretion, which can lead to rebound hypoglycemia. Therefore, glucose water in a bottle should be avoided or used sparingly for mild cases of hypoglycemia that do not respond to breast milk.
Correct Answer is D
Explanation
A. Dressing the infant in only a T-shirt and diaper is not recommended during phototherapy because it reduces the amount of skin exposed to the light, which is necessary for effective treatment. The infant should be minimally clothed to maximize light exposure.
B. Restricting parental and oral fluids is incorrect. Adequate hydration is crucial during phototherapy to prevent dehydration, as the treatment can increase fluid loss through the skin.
C. Keeping the infant supine at all times is not necessary. The infant should be repositioned frequently to ensure all areas of the skin are exposed to the phototherapy light, which helps in reducing bilirubin levels more effectively.
D. Keeping the infant's eyes covered under the light is essential to protect the eyes from potential damage caused by the intense phototherapy light. This is a standard practice to prevent retinal damage and other eye complications.
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