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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 B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

A. Contact the provider within 48 hr to obtain a prescription for the restraints. B. Remove the restraints from the client's wrists every 2 hr C. Check that one finger will fit between the client's wrists and the restraints. D. Fasten the restraints' ties to the bed's side rails.

Correct Answer is B

Explanation

A. Contact the provider within 48 hr to obtain a prescription for the restraints: A provider’s order for restraints must be obtained immediately or within a very short time frame, usually within 1 hour, depending on facility policy. Waiting 48 hours would be inappropriate and could lead to violation of patient rights.

B. Remove the restraints from the client's wrists every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, provide range of motion exercises, and evaluate the continued need for restraints. This practice ensures client safety, prevents complications such as pressure injuries, and respects client dignity.

C. Check that one finger will fit between the client's wrists and the restraints: The correct practice is to ensure that two fingers can fit between the restraint and the skin to prevent circulatory impairment and skin breakdown. One finger would be too tight and could increase the risk of injury.

D. Fasten the restraints' ties to the bed's side rails: Restraints should always be tied to the bed frame, not the side rails. Attaching restraints to movable parts like side rails can cause injury if the rail is lowered or repositioned, leading to unnecessary strain or trauma to the client.

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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.

Nursing Test Bank

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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.