A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
Blood glucose 110 mg/dL.
Urine protein of 3+.
Hemoglobin 13 g/dL.
Deep tendon reflexes of 2+.
The Correct Answer is B
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.
Choice B rationale:
Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.
Choice C rationale:
Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.
Choice D rationale:
Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.
Correct Answer is A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
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