A nurse is caring for a client who is at 15 weeks of gestation during a routine prenatal visit.
Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? Select all that apply.
BUN.
Potassium.
Hct.
Weight.
Heart rate.
Sodium.
Hgb.
Urine-specific gravity
Correct Answer : D,E,H
Choice A rationale:
BUN is within the normal range (10 to 20 mg/dL), so it's not an indication of a potential complication.
Choice B rationale:
Potassium is slightly below the normal range (3.5 to 5 mEq/L), indicating potential hypokalemia, which can be a complication.
Choice C rationale:
Hct is at the upper limit of the normal range (33% to 49%), but still within normal, so it's not a complication.
Choice D rationale:
Weight loss of 2 kg in 1 month during pregnancy is concerning and could indicate a complication such as hyperemesis gravidarum.
Choice E rationale:
Heart rate is slightly elevated, which could indicate dehydration, a potential complication.
Choice F rationale:
Sodium is slightly below the normal range (136 to 145 mEq/L), but this alone is not typically a complication of pregnancy.
Choice G rationale:
Hgb is within the normal range (11 to 16 g/dL), so it's not a complication.
Choice H rationale:
Urine-specific gravity is above the normal range (1.005 to 1.030), indicating potential dehydration, a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice Arationale:
Decreasing the rate of IV fluids would not address the issue of late decelerations, which indicate fetal hypoxia.
Choice Brationale:
Fetal scalp stimulation is used to assess fetal well-being, but it would not address the issue of late decelerations.
Choice C rationale:
Administering oxygen via a face mask can increase the amount of oxygen available to the fetus, potentially alleviating the hypoxia causing the late decelerations.
Choice D rationale:
Elevating the client’s head would not address the issue of late decelerations.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should use fingers to exert upward pressure on the presenting part to relieve cord compression, which is the immediate priority in this emergency situation.
Choice B rationale:
Administering a tocolytic medication is not the immediate priority. It may be done later to inhibit uterine contractions.
Choice C rationale:
Applying oxygen to the client is important, but it’s not the first action. The nurse needs to relieve cord compression first.
Choice D rationale:
Wrapping the cord in a sterile towel and moistening with warm sterile normal saline is important, but it’s not the first action. The nurse needs to relieve cord compression first.
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