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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answer is Choice A, Choice D, Choice E.
Choice A rationale
Pain during intercourse, also known as dyspareunia, is a common symptom of endometriosis. Endometrial tissue growing outside the uterus can infiltrate the pelvic organs and ligaments, causing pain and discomfort during sexual activity due to pressure and inflammation in these areas.
Choice B rationale
Painless heavy menstrual bleeding is not typically associated with endometriosis. Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus, which responds to hormonal fluctuations of the menstrual cycle, often leading to painful periods (dysmenorrhea) and potentially heavy bleeding accompanied by pain.
Choice C rationale
Unexplained weight gain is not a typical symptom directly linked to endometriosis. While hormonal imbalances can occur with endometriosis, they do not usually manifest as unexplained weight gain. Other factors are more likely to contribute to weight changes.
Choice D rationale
Infertility is a significant concern for many individuals with endometriosis. The presence of endometrial implants, adhesions, and scarring in the pelvic cavity can distort the anatomy of the reproductive organs, interfering with ovulation, fertilization, and implantation of a fertilized egg.
Choice E rationale
Pain during the menstrual period, known as dysmenorrhea, is a hallmark symptom of endometriosis. The ectopic endometrial tissue undergoes cyclical bleeding and shedding, similar to the uterine lining, but this occurs outside the uterus, causing inflammation, pain, and potentially the formation of scar tissue and adhesions.
Correct Answer is B
Explanation
Choice A rationale
Urinary tract infections primarily involve the urinary system, causing symptoms like dysuria, frequency, and urgency. While some overlap in symptoms might occur, the green-yellow vaginal discharge, itching, and foul odor are not typical of a UTI.
Choice B rationale
Trichomoniasis, caused by the parasite *Trichomonas vaginalis*, is a sexually transmitted infection that commonly presents with a frothy, green-yellow vaginal discharge, vulvar itching, and a distinct, often foul, odor. The client's recent unprotected sexual activity with new partners supports this possibility.
Choice C rationale
Herpes simplex virus typically causes painful vesicular lesions on the genitals, perineum, or cervix. While there might be some discomfort, the primary symptoms are the characteristic blisters, not typically a green-yellow discharge and foul odor.
Choice D rationale
Human papillomavirus (HPV) is a sexually transmitted infection that can cause genital warts or lead to cervical cancer. However, it typically does not present with a green-yellow vaginal discharge, itching, or a foul odor. Many HPV infections are asymptomatic. .
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