A nurse is caring for a client at 28 weeks of gestation who has a blood pressure reading of 162/108 mm Hg, and 4 hours previously it was 148/98 mm Hg. Which of the following orders should the nurse anticipate receiving? (Select all that apply))
Complete blood count (CBC).
Aspartate aminotransferase (AST) and alanine transaminase (ALT).
Serum creatinine.
Fetal ultrasound.
Contraction stress test.
Amniocentesis.
Correct Answer : A,B,C,D
Choice A rationale
CBC will detect abnormalities such as anemia or infection, which may correlate with preeclampsia or HELLP syndrome.
Choice B rationale
Elevated AST and ALT levels indicate liver damage, a potential sign of severe preeclampsia or HELLP syndrome.
Choice C rationale
Serum creatinine helps assess kidney function, as preeclampsia can impair renal perfusion leading to elevated levels.
Choice D rationale
Fetal ultrasound assesses fetal growth, amniotic fluid volume, and placental function, critical in monitoring preeclampsia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Delusions indicate severe psychiatric conditions like postpartum psychosis, not depression. Depression involves low mood, energy, and interest, without detachment from reality. Delusions reflect loss of reality testing, requiring different interventions. Common in severe psychoses like schizophrenia.
Choice B rationale
Euphoria indicates abnormally elevated mood, seen in manic episodes of bipolar disorder, not depression. Depression involves sadness, hopelessness, and low energy. Euphoria's excessive positivity contrasts with depressive symptoms, including impaired functioning and behavior regulation.
Choice C rationale
Flat affect signifies reduced emotional expression, common in depression. Depressed individuals exhibit lack of response to pleasurable activities, social withdrawal, and emotional blunting. This impairment in emotional expressiveness reflects major depressive disorder.
Choice D rationale
Insomnia, common in depression, affects sleep patterns, causing difficulty initiating or maintaining sleep. It contributes to fatigue, cognitive impairment, and mood disturbances. Insomnia reflects dysregulated sleep-wake cycles in depression, impacting daily functioning.
Choice E rationale
Fatigue is frequent in depression, marked by persistent tiredness despite rest. It stems from sleep disturbances, low energy, and anhedonia. Fatigue affects concentration, motivation, and physical activity, manifesting as psychomotor retardation in depression.
Correct Answer is B
Explanation
Choice A rationale
Uterine atony refers to a lack of muscle tone in the uterus, leading to postpartum hemorrhage, not subinvolution.
Choice B rationale
Prolonged lochia discharge indicates incomplete uterine involution, as the uterus has not returned to its pre-pregnancy size.
Choice C rationale
Severe cramping may be related to other postpartum complications and is not specific to subinvolution.
Choice D rationale
High fever is more indicative of an infection rather than subinvolution of the uterus.
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