A nurse is assisting with the care of a client who is pregnant.
Nurses' Notes.
0900: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.
Client also reports urinary frequency and decreased fetal movement.
Client is a. gravida 3, para 2 with one preterm birth.
The nurse is reviewing the client's medical record.
Select 4 findings that the nurse should identify as a potential prenatal complication
Blood pressure.
Respiratory rate.
Gravida/parity.
Fetal activity.
Headache.
Urine ketones.
Urine protein.
Correct Answer : A,D,E,G
Choice A rationale:
Blood pressure is a crucial parameter to monitor in a pregnant woman. A significant increase in blood pressure could indicate a condition called preeclampsia, which is characterized by high blood pressure and damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby.
Choice B rationale:
While the respiratory rate is an important vital sign, it does not directly indicate a prenatal complication in this context. Normal respiratory rates for an adult range from 12 to 20 breaths per minute. Changes could indicate a respiratory problem but not specifically a prenatal complication.
Choice C rationale:
Gravida/parity is a standard way to denote a woman's reproductive history but does not indicate a prenatal complication. Gravida refers to the number of times a woman has been pregnant, regardless of the outcome, while parity refers to the number of pregnancies carried past 20 weeks, regardless of whether they were born alive or stillborn.
Choice D rationale:
Decreased fetal activity can be a sign of distress in the fetus. It could indicate complications such as poor oxygenation or other conditions that could affect the health of the baby. It's important for pregnant women to monitor their baby's movements daily after 28 weeks.
Choice E rationale:
A severe headache unrelieved by acetaminophen in a pregnant woman could be a sign of preeclampsia, especially when accompanied by other symptoms such as high blood pressure and changes in vision. This should be evaluated immediately.
Choice F rationale:
Urine ketones are usually checked in pregnant women who have symptoms of a condition called ketoacidosis, which is often seen in women with gestational diabetes. However, this condition is not indicated in this scenario.
Choice G rationale:
Protein in the urine is another potential sign of preeclampsia. It's caused by kidney problems resulting from the high blood pressure. In normal conditions, protein should not be present in urine or should be very low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
An entry on a nursing blog, while potentially informative, does not provide the same level of evidence-based information as a peer-reviewed journal article. Blog posts may not undergo rigorous peer review and may lack the scientific rigor and credibility associated with peer-reviewed research. Therefore, choice A is not the best source for evidence-based information.
Choice B rationale:
Information from a wound care product vendor may be biased and influenced by commercial interests. Vendors often aim to promote their products, and the information they provide may not be impartial or based on rigorous scientific research. Therefore, choice B is not the best source for evidence-based information.
Choice C rationale:
A peer-reviewed journal article is considered one of the most reliable sources of evidence-based information in healthcare. Such articles undergo a thorough review process by experts in the field to ensure the accuracy, quality, and validity of the research findings. Peer-reviewed articles provide credible and up-to-date information based on scientific research and are widely recognized as a gold standard in evidence-based practice. Therefore, choice C is the correct answer as it offers the best evidence-based information.
Choice D rationale:
First-hand experience with wound care products, while valuable, may not necessarily provide the most comprehensive or up-to-date information. Personal experiences can vary, and healthcare practices evolve over time based on research and new evidence. Therefore, choice D is not the best source for evidence-based information.
Correct Answer is B
Explanation
Choice A rationale:
Fever. Fever is not an adverse effect of hypoglycemia. Fever is usually associated with an elevated body temperature, often due to infection or other inflammatory conditions, and is not directly related to low blood sugar levels.
Choice B rationale:
Shakiness. Shakiness is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body responds with symptoms like trembling or shakiness, which is caused by the release of stress hormones like epinephrine. These symptoms are the body's way of signaling the need for immediate glucose intake to raise blood sugar levels.
Choice C rationale:
Increased urination. Increased urination is not a typical symptom of hypoglycemia. In fact, frequent urination may be associated with hyperglycemia (high blood sugar levels) in conditions like diabetes mellitus.
Choice D rationale:
Thirst. Thirst is not a direct symptom of hypoglycemia. Thirst is more commonly associated with hyperglycemia, where high blood sugar levels lead to increased urine output, causing dehydration and subsequent thirst. In hypoglycemia, the focus is on correcting the low blood sugar levels rather than managing thirst.
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