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A nurse is assisting with the care of a client who is pregnant

The nurse is reviewing the client's medical record.

Select 4 findings that the nurse should identify as a potential prenatal complication.

Urine protein

Respiratory rate

Gravida/parity

Urine ketones

Headache

Fetal activity

Blood pressure

Answer and Explanation

Correct Answer : A,E,F,G

Urine protein: The presence of 3+ proteinuria is a significant finding suggestive of preeclampsia. Protein in the urine indicates renal involvement due to endothelial dysfunction, which is a hallmark complication in hypertensive disorders of pregnancy and needs immediate attention.
Respiratory rate: A respiratory rate of 16/min falls within the normal adult range of 12 to 20 breaths per minute. There is no evidence of respiratory distress, tachypnea, or bradypnea, so this finding does not suggest a prenatal complication.
Gravida/parity: Although the client has a history of one preterm birth, gravida and parity alone are not indicators of a current prenatal complication. It is important background information but does not point directly to an acute complication at this time.
Urine ketones: The absence of ketones in the urine is a normal finding. If ketones were present, it could suggest dehydration, starvation, or uncontrolled diabetes, but since they are negative, ketones are not a concern for prenatal complication here.
Headache: A severe headache unrelieved by acetaminophen in a pregnant woman can signal worsening hypertension or preeclampsia. Persistent headaches are a concerning symptom that warrants immediate evaluation and management to prevent maternal and fetal harm.
Fetal activity: Decreased fetal movement is a worrisome sign of possible fetal compromise, such as hypoxia or placental insufficiency. Reduced movements require further fetal assessment and monitoring to ensure fetal well-being.
Blood pressure: A blood pressure reading of 162/112 mm Hg is severely elevated and meets the diagnostic criteria for severe preeclampsia. Uncontrolled hypertension during pregnancy places both the mother and fetus at significant risk for serious complications.

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Correct Answer is D

Explanation

A. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.

B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.

C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.

D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL) B. A client who has a spinal cord injury and needs a dressing change C. A client who has a temperature of 38.4° C (101.1 F) and appears confused D. A client who had a hip arthroplasty and is requesting pain medication

Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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A nurse is assisting with the care of a client who is pregnant The nurse is reviewing the client's medical record. Select 4 findings that the nurse should identify as a potential prenatal complication.

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A nurse is assisting with the care of a client who is pregnant

The nurse is reviewing the client's medical record.

Select 4 findings that the nurse should identify as a potential prenatal complication.