A nurse is caring for a 35-year-old female client who is at 37 weeks of gestation in the antepartum unit.
Complete the following sentence using the drop-down options: The nurse’s greatest concern is the client’s risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}
The nurse’s greatest concern is the client’s risk of developing preeclampsia with severe features related to elevated blood pressure and proteinuria.
Rationale for correct answers
Preeclampsia with severe features is diagnosed when a pregnant client has blood pressure ≥160/110 mm Hg, as seen in this case (162/112 mm Hg), along with signs of end-organ damage, such as proteinuria, thrombocytopenia, and elevated liver enzymes. The client has proteinuria, as detected in urinalysis, and laboratory markers of potential organ dysfunction, including elevated AST, ALT, LDH, and creatinine, all supporting progression to severe disease.
Elevated blood pressure is a hallmark of preeclampsia and places the client at risk for stroke, placental abruption, and fetal complications. Proteinuria (urinary excretion of excess protein due to endothelial dysfunction) confirms a worsening condition. Immediate interventions, including magnesium sulfate for seizure prevention and antihypertensives, are warranted.
Rationale for incorrect Response 1 options
- Gestational hypertension: Unlike gestational hypertension, which is hypertension without proteinuria or organ dysfunction, this client meets criteria for severe preeclampsia, making gestational hypertension an incomplete diagnosis.
- Placental abruption: No vaginal bleeding or symptoms like sudden abdominal pain suggestive of placental separation.
- Chorioamnionitis: No fever or foul-smelling amniotic fluid, ruling out intrauterine infection.
Rationale for incorrect Response 2 options
- Fetal distress: While late decelerations indicate uteroplacental insufficiency, the primary concern remains maternal preeclampsia, which secondarily leads to fetal distress.
- Oliguria: Though urine output is reduced, it is not the leading diagnostic criterion over hypertension and proteinuria.
- Contractions: Preterm labor is occurring, but contractions are not the main threat compared to severe preeclampsia risks.
Rationale for incorrect Response 3 options
- Vaginal bleeding: No signs of bleeding, ruling out placental abruption or other hemorrhagic complications.
- Fever: No elevated temperature indicative of infection.
- Hypoxia: Oxygen saturation is normal (98%), and the primary issue relates to vascular dysfunction rather than respiratory compromise.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Assisting the patient onto her left side can improve uteroplacental perfusion by relieving pressure on the vena cava, potentially improving fetal oxygenation and addressing fetal heart rate decelerations. This position maximizes blood flow to the uterus and placenta.
Choice B rationale
A vaginal examination is crucial to assess for umbilical cord prolapse, especially in the presence of fetal heart rate decelerations or bradycardia. Prolapse of the cord can severely compromise fetal oxygen supply, necessitating immediate intervention.
Choice C rationale
Discontinuing the oxytocin infusion is essential if fetal heart rate abnormalities occur, as oxytocin stimulates uterine contractions, which can further compromise fetal oxygenation if the fetus is already stressed. Reducing or stopping contractions can alleviate fetal distress.
Choice D rationale
Administering oxygen at 10 L/min via nonrebreather face mask increases the maternal oxygen supply, which in turn can increase the oxygen available to the fetus across the placenta. This is a standard intervention for fetal distress.
Choice E rationale
Notifying the health care provider is a critical step to communicate the fetal heart rate abnormalities and the interventions implemented. The provider can then assess the situation, determine the underlying cause, and order further management.
Choice F rationale
Stopping the magnesium sulfate is indicated primarily for signs of magnesium toxicity in the mother, such as respiratory depression, loss of deep tendon reflexes, or decreased urine output. While magnesium sulfate can affect the fetus, it is not a first-line intervention for fetal heart rate abnormalities unless related to preterm labor management.
Correct Answer is A
Explanation
Choice A rationale
Rubella immunization is contraindicated during pregnancy due to the theoretical risk to the fetus from the live attenuated vaccine. Administering the vaccine immediately after delivery ensures the mother develops immunity before subsequent pregnancies, protecting future fetuses from congenital rubella syndrome.
Choice B rationale
Administering the rubella vaccine during the first trimester of pregnancy is contraindicated because it is a live attenuated vaccine and poses a potential risk to the developing fetus, potentially causing congenital rubella syndrome which can lead to serious birth defects.
Choice C rationale
Administering the rubella vaccine during the third trimester of pregnancy is also contraindicated due to the potential risk to the fetus. While the risk might be lower later in pregnancy, it is still not recommended to administer live vaccines during gestation.
Choice D rationale
Waiting until the next attempt to get pregnant is not the optimal timing. The recommendation is to administer the rubella vaccine immediately postpartum to ensure the mother is immune before any future pregnancies, thus preventing potential harm to subsequent fetuses. .
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