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
Explanation
Choice A rationale
The pulsating cord felt in the vagina indicates umbilical cord prolapse, a critical obstetric emergency. Immediately applying upward pressure to the presenting fetal part (vertex) manually elevates the fetus off the prolapsed cord. This action aims to relieve pressure on the umbilical vessels, thereby preventing fetal hypoxia and maintaining oxygen supply to the fetus until delivery can be expedited.
Choice B rationale
While continuous fetal monitoring is essential, adjusting the monitor is not the immediate priority in the presence of a prolapsed umbilical cord and a significantly decreased fetal heart rate. The immediate intervention is to relieve pressure on the cord to improve fetal oxygenation.
Choice C rationale
Calling the provider and preparing for an emergency cesarean section are necessary steps that should follow the immediate intervention. However, the very first action must be to relieve pressure on the prolapsed cord to prevent fetal compromise.
Choice D rationale
Positioning the client on her left side is a standard intervention for fetal distress or suspected vena cava syndrome, but in the case of a prolapsed umbilical cord, it is not the most immediate and effective action. Direct pressure on the presenting part is required to alleviate cord compression. .
Correct Answer is []
Explanation
Rationale for Correct Condition
Postpartum hemorrhage is defined as excessive blood loss (>500 mL in vaginal delivery) and is often caused by uterine atony, impaired uterine contraction, or trauma. This client exhibits a boggy uterus, heavy vaginal bleeding, and clot passage, all hallmark signs of postpartum hemorrhage rather than placenta previa, placental abruption, or preeclampsia.
Rationale for Correct Risk Factors
Fetal macrosomia contributes to uterine overdistension, increasing the risk of uterine atony and inefficient contractions post-delivery. History of smoking affects vascular integrity, increasing placental dysfunction risks, which can contribute to postpartum bleeding.
Rationale for Correct Assessment Findings
Uterine atony is the most common cause of postpartum hemorrhage. A boggy uterus indicates insufficient contraction to compress blood vessels after placental delivery. Heavy vaginal bleeding signifies excessive blood loss, requiring intervention to prevent hypovolemia and hemodynamic instability.
Rationale for Incorrect Conditions
Placenta previa presents with painless antepartum bleeding, not postpartum hemorrhage. Placental abruption leads to painful bleeding before delivery and can cause fetal distress. Preeclampsia involves hypertension and proteinuria, which are absent here.
Rationale for Incorrect Risk Factors
Prolonged labor can increase hemorrhage risk but is not relevant here. Primipara status does not apply, as the client is multiparous. Maternal weight may contribute but is not a primary hemorrhage risk factor.
Rationale for Incorrect Assessment Findings
Blood pressure helps assess hemorrhage severity but is not a direct finding of uterine atony. Urine output reflects fluid balance but does not confirm postpartum hemorrhage. Cramping is expected postpartum and does not indicate excessive bleeding.
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