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A nurse in an antepartum unit is caring for a client.

Exhibits

For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.

A.

Purulent amniotic fluid

B.

Elevated uric acid level

C.

Fever

D.

Decreased platelet count

E.

Blurred vision

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Findings Consistent with Chorioamnionitis:

  • Purulent amniotic fluid
  • Fever

Findings Consistent with Preeclampsia:

  • Elevated uric acid level
  • Decreased platelet count
  • Blurred vision

Rationale:

  • Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
  • Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
  • Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
  • Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
  • Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.


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Related Questions

Correct Answer is B

Explanation

A. Breathlessness is not a typical symptom of a sliding hiatal hernia. However, in severe cases, large hernias may cause shortness of breath due to pressure on the diaphragm.
B. Heartburn (acid reflux) is a common symptom because the hernia allows stomach acid to move up into the esophagus, causing irritation and discomfort.
C. Abdominal cramping is not a primary symptom of a sliding hiatal hernia. Cramping is more commonly associated with gastrointestinal conditions like irritable bowel syndrome (IBS) or gastroenteritis.
D. Constipation is not directly linked to a sliding hiatal hernia. Instead, symptoms usually involve gastroesophageal reflux disease (GERD)-related issues, such as heartburn and regurgitation.

Correct Answer is C

Explanation

A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.

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