A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia?

Client has a twin sister.

Her mother had preeclampsia during pregnancy.

This is the client's second pregnancy.

Her sister-in-law had gestational hypertension.

Answer and Explanation

The Correct Answer is B

A. Client has a twin sister.

Having a twin sister does not directly increase the client's risk of developing preeclampsia. While twin pregnancies are associated with higher rates of certain complications, such as preterm birth and gestational hypertension, having a twin sister herself does not inherently increase her risk of preeclampsia.

B. Her mother had preeclampsia during pregnancy.

This is the correct choice. A history of preeclampsia in the client's mother is a significant risk factor for preeclampsia in the client herself. Preeclampsia has a genetic component, and women with a family history of the condition, especially in their mothers, are at increased risk of developing it during their own pregnancies.

C. This is the client's second pregnancy.

While the number of pregnancies a woman has experienced can influence her risk of certain pregnancy complications, such as placental abnormalities, it is not as strong a risk factor for preeclampsia as a family history of the condition. Preeclampsia can occur in both first and subsequent pregnancies, regardless of the number of pregnancies a woman has had.

D. Her sister-in-law had gestational hypertension.

Gestational hypertension is a related condition to preeclampsia and shares some risk factors, such as high blood pressure during pregnancy. However, a sister-in-law having gestational hypertension does not directly increase the client's risk of preeclampsia. While it may suggest a family predisposition to hypertensive disorders during pregnancy, it is not as specific a risk factor for preeclampsia as a direct family history of the condition, such as in the client's mother.

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Correct Answer is C

Explanation

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

- This option is not appropriate because after a right-sided modified-radical mastectomy, it's generally contraindicated to use the affected arm (right arm in this case) for blood pressure measurements, IV lines, or blood draws. This is because such procedures can impede lymphatic drainage and increase the risk of lymphedema. Therefore, the unaffected arm is typically preferred for these purposes to reduce the risk of complications.

B. Encourage her to turn, cough, and deep breathe at frequent intervals.

- While turning, coughing, and deep breathing are essential postoperative nursing interventions to prevent respiratory complications such as pneumonia, they are not specific to the unique needs of a woman who has undergone a mastectomy. These interventions are more focused on general postoperative care rather than addressing the specific concerns related to mastectomy, such as lymphedema management.

C. Position her right arm below heart level.

- This is the correct choice. Positioning the right arm below heart level helps reduce swelling and promotes lymphatic drainage, particularly after surgery involving the lymph nodes, as in a mastectomy. This positioning aids in preventing complications such as lymphedema and supports optimal circulation and fluid balance in the affected arm.

D. Ask the client how she feels about having her breast removed.

- While emotional support and addressing the client's feelings are important aspects of care for a woman who has undergone a mastectomy, this intervention is more appropriate during psychosocial assessment and counseling sessions, rather than immediately postoperatively. At this stage, the focus should be primarily on physical recovery and addressing immediate postoperative needs, such as pain management and prevention of complications like lymphedema. Emotional support can certainly be provided, but it should not be the primary intervention immediately following surgery.

A. "I won't use my birth control pills for at least a year or two." B. "I will be sure to avoid getting pregnant for at least 1 year." C. "My blood pressure will continue to be increased for about 6 more months." D. "My intake of iron will have to be closely monitored for 6 months."

Correct Answer is B

Explanation

A. "I won't use my birth control pills for at least a year or two." - This statement does not accurately reflect the teaching provided. After treatment for gestational trophoblastic disease, it is important for the woman to avoid pregnancy for a specified period of time to allow for monitoring and to reduce the risk of complications. However, the use of birth control pills is typically recommended to prevent pregnancy during this period.

B. "I will be sure to avoid getting pregnant for at least 1 year." - This statement demonstrates understanding of the teaching. After treatment for gestational trophoblastic disease, healthcare providers typically recommend avoiding pregnancy for at least one year. This allows for monitoring of hCG levels to ensure they return to normal and to reduce the risk of recurrence.

C. "My blood pressure will continue to be increased for about 6 more months." - This statement is not related to the teaching about gestational trophoblastic disease. Blood pressure may be affected during pregnancy, but it is not a specific concern related to treatment for gestational trophoblastic disease.

D. "My intake of iron will have to be closely monitored for 6 months." - This statement is not directly related to the teaching about gestational trophoblastic disease. While monitoring of iron levels may be important for overall health, it is not a specific recommendation related to treatment for this condition.

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A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

Correct Answer is C

Explanation

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?

Correct Answer is B

Explanation

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