A nurse is caring for a client who is pregnant.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Blood pressure
Urine ketones
Urine protein Gravida/parity
Report of headache
Respiratory rate
Fetal activity
Correct Answer : A,C,D,F
A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.
B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.
C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.
D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.
E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.
F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client upset about a change in routine does not present an immediate threat to their health.
B. Assistance with ADLs is important but not urgent compared to a possible adverse drug reaction.
C. A sore throat in a client taking clozapine may indicate agranulocytosis, a potentially life-threatening condition that requires immediate evaluation.
D. Mocking others is disruptive but not a priority over a potential medical emergency.
Correct Answer is C
Explanation
A. Ranitidine: An H2 receptor blocker, typically used to reduce stomach acid, is unnecessary since the stomach has been removed.
B. Vitamin K: Although important for clotting, vitamin K absorption is not significantly affected by total gastrectomy.
C. Vitamin B12: Clients require lifelong vitamin B12 supplementation (usually via intramuscular injections) after total gastrectomy to prevent deficiency and associated complications such as anemia and neurological impairments.
D. Metoclopramide: A prokinetic agent used to enhance gastric motility, which is not relevant after total gastrectomy.
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