A nurse is caring for a client who is at 34 weeks of gestation.
The client reports headache, dizziness, and blurred vision for 1 week.
The nurse notes 3+ edema in lower extremities and deep tendon reflexes (DTRs) 3+ with positive clonus.
The fetal heart rate (FHR) is 140 with minimal variability.
The nurse is reviewing the client’s electronic medical record to develop a plan of care.
Which condition is the client most likely experiencing, what are two actions the nurse should take to
Preeclampsia
Chronic hypertension
Neurologic status
Liver function studies
The Correct Answer is A
Choice A rationale
The client’s symptoms of headache, dizziness, blurred vision, 3+ edema in lower extremities, deep tendon reflexes (DTRs) 3+ with positive clonus, and a fetal heart rate (FHR) of 140 with minimal variability are indicative of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. It usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious complications for both the mother and baby. To address this condition, the nurse should: Monitor the client’s blood pressure regularly. Administer prescribed medications to control blood pressure and prevent seizures. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Chronic hypertension is a possibility, but it does not fully explain the client’s symptoms. While chronic hypertension can cause headaches and dizziness, it does not typically cause 3+ edema in the lower extremities or positive clonus. Furthermore, chronic hypertension would have been present before the pregnancy or diagnosed before the client reached 20 weeks of gestation.
Choice C rationale
While the client’s symptoms of headache, dizziness, and blurred vision could suggest a neurologic issue, the presence of 3+ edema in the lower extremities and positive clonus are more indicative of preeclampsia. Neurologic status would be monitored as part of the care for a client with preeclampsia.
Choice D rationale
Liver function studies would be relevant if there were symptoms or signs suggesting liver involvement such as upper right abdominal pain, nausea or vomiting, or jaundice. However, the client’s symptoms are more indicative of preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Step 1 is to identify the concentration of the medication. From the search results, enoxaparin comes in pre-filled syringes with different concentrations, one of which is 30 mg/0.3 mL56.
Step 2 is to calculate the volume to be administered. Since the client is due to receive 30 mg of enoxaparin and the concentration is 30 mg/0.3 mL, the calculation is (30 mg ÷ 30 mg) × 0.3 mL. The final calculated answer is 0.3 mL.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Variable decelerations are not related to fetal head compression. Fetal head compression typically results in early decelerations, not variable ones.
Choice B rationale
Variable decelerations are indeed due to umbilical cord compression. They are quick decreases in fetal heart rate that vary with uterine contractions. This can be a sign that the baby’s blood flow is reduced if variable decelerations happen over and over.
Choice C rationale
Uteroplacental insufficiency typically results in late decelerations, not variable ones. Late decelerations are a sign of fetal hypoxia and are associated with uteroplacental insufficiency.
Choice D rationale
While certain medications can affect the fetal heart rate, variable decelerations are not typically a result of the administration of narcotic analgesics.
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