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 ["B","C","E"]
Explanation
Choice A rationale
Severe cramping and pelvic pain are more indicative of an inevitable or incomplete abortion, where the pregnancy is no longer viable and the body is actively trying to expel the uterine contents. In a threatened abortion, the symptoms are typically milder.
Choice B rationale
A closed cervix upon examination is a key finding in a threatened abortion. It indicates that the uterus is not yet dilating or effacing, suggesting that the pregnancy might still be maintained. Cervical dilation signifies progression towards abortion.
Choice C rationale
Mild to moderate lower abdominal cramping is a common symptom of a threatened abortion. These cramps result from uterine irritability and contractions as the body reacts to potential pregnancy loss. The intensity is less severe than in later stages of abortion.
Choice D rationale
Passage of fetal tissue is a definitive sign of an incomplete or complete abortion, meaning the pregnancy has already been lost and the products of conception are being expelled. This would not be expected in a threatened abortion.
Choice E rationale
Bright red vaginal bleeding is a common symptom of a threatened abortion, indicating disruption at the decidual-trophoblastic interface. The bleeding can range from spotting to light bleeding and suggests a potential threat to the pregnancy.
Correct Answer is B
Explanation
Choice A rationale
The fetal heart indeed pumps blood to both the placenta, where oxygen and nutrients are obtained, and to the developing organs, which require these substances for growth and function. This dual circulation is essential for fetal development. The normal circulatory pattern ensures that oxygenated blood returns from the placenta to nourish the fetal tissues, while deoxygenated blood is transported back to the placenta for gas exchange.
Choice B rationale
Maternal and fetal blood do not mix under normal physiological conditions. The exchange of gases, nutrients, and waste products occurs across the placental barrier, which consists of fetal and maternal tissues but keeps their bloodstreams separate. This separation prevents potential immune reactions and maintains distinct circulatory systems for the mother and the fetus.
Choice C rationale
The placenta serves as the vital site for gas exchange in the fetus. Oxygen and carbon dioxide are exchanged between the maternal and fetal blood across the placental membranes via diffusion. Oxygen-rich blood from the mother is delivered to the fetus, while carbon dioxide, a waste product of fetal metabolism, moves from the fetus to the mother for elimination.
Choice D rationale
The umbilical arteries are responsible for carrying deoxygenated blood and waste products from the fetus to the placenta. This deoxygenated blood is then oxygenated and cleared of waste at the placenta before returning to the fetus via the umbilical vein. This flow pattern is crucial for maintaining the fetal environment and supporting its development.
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