Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Airborne precautions should be initiated for clients with tuberculosis (TB) who have a productive cough. TB is transmitted through the airborne route when an infected individual coughs, sneezes, or talks, releasing infectious droplets into the air. Airborne precautions include the use of negative-pressure isolation rooms and N95 respirators for healthcare workers to prevent the spread of TB.

Choice B rationale:

Protective precautions are not typically used for clients with TB. Protective precautions are more commonly employed for clients with compromised immune systems to protect them from infection.

Choice C rationale:

Droplet precautions are not sufficient for clients with TB because TB is primarily transmitted via airborne particles, not droplets. Droplet precautions are used for diseases like influenza or meningitis, which are transmitted through larger respiratory droplets.

Choice D rationale:

Contact precautions are not appropriate for clients with TB because TB is primarily transmitted through the airborne route. Contact precautions are typically used for diseases that are transmitted through direct contact with the client or contaminated surfaces.

A. 8 oz fruit yogurt. B. 8 oz raw spinach. C. 8 oz chopped hard-boiled egg. D. 8 oz brown rice.

Correct Answer is C

Explanation

Choice A rationale:

8 oz of fruit yogurt contains protein, but it is not as protein-rich as the other options. Yogurt is more commonly consumed for its probiotic benefits and calcium content.

Choice B rationale:

8 oz of raw spinach contains some protein but is not a high source of protein compared to the other options. Spinach is often chosen for its high iron and fiber content.

Choice C rationale:

8 oz of chopped hard-boiled egg is a significant source of protein. Eggs are well-known for their high-quality protein content.

Choice D rationale:

8 oz of brown rice is not a high source of protein compared to the other options. While it does contain some protein, it is primarily a carbohydrate-rich food.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough.Which type of isolation precautions should the nurse initiate for the client?

Correct Answer is A

Explanation

A nurse is assisting a client who has cancer to select high-protein foods. Which of the following foods should the nurse recommend as the highest source of protein?

Correct Answer is C

Explanation

A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

A nurse is collecting data from a client who is 2 days postpartum.The client tells the nurse she cannot afford to pay for baby formula.The nurse should refer the client to which of the following members of the interprofessional team?

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

A nurse is caring for a client who has hypoglycemia.The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

A nurse is assisting with discharge planning for a client who is prescribed home oxygen at 1 to 2 L/min.The nurse should ensure that the client has which of the following supplies upon discharge?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis.Which of the following interventions should the nurse recommend to include in the plan?

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?