A nurse is caring for a client who is at 33 weeks of gestation.
Medical History Gravida 2 Para 1 Preeclampsia
The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.
Platelet count 90.000/mm3
Hematuria
Positive clonus
Proteinuria 2+
Leukorrhea
BUN 40 mg/dL
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"C"}}
Platelet count 90,000/mm3: Sign of Potential Worsening Condition - A decreased platelet count may indicate worsening preeclampsia and a risk of developing HELLP syndrome or thrombocytopenia.
Hematuria: Sign of Potential Worsening Condition - Hematuria suggests potential kidney involvement, which is a serious complication of preeclampsia, indicating a worsening condition. Positive clonus: Sign of Potential Worsening Condition - Positive clonus is a neurological sign associated with preeclampsia and indicates hyperreflexia, which can lead to seizures if untreated. Proteinuria 2+: Sign of Potential Worsening Condition - Increased proteinuria indicates ongoing kidney dysfunction, which is a worsening sign of preeclampsia.
Leukorrhea: Sign of Potential Improvement - Leukorrhea, an increase in vaginal discharge, may indicate a reduction in cervical mucus plug, which is a normal finding in late pregnancy.
BUN 40 mg/dL: Sign of Potential Worsening Condition - Elevated blood urea nitrogen (BUN) levels indicate impaired kidney function, which is a worsening sign of preeclampsia and can lead to complications such as acute kidney injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Using a 21-gauge needle may be too large for a newborn, increasing the risk of discomfort and tissue damage.
B. Inserting the needle at a 45° angle may not be appropriate for intramuscular injections in newborns. The preferred angle is typically 90°.
C. Administering the injection into the vastus lateralis muscle is the recommended site for hepatitis B vaccination in newborns. This site is located on the anterior lateral aspect of the thigh and provides good muscle mass for injection.
D. Vigorously massaging the site following the injection is not recommended as it may increase discomfort and tissue trauma. Instead, gentle pressure can be applied to the site to help reduce discomfort.
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
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