A nurse is caring for a client who is pregnant.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Daily weights: This task can be delegated to ensure consistent monitoring of the client's weight, which is crucial for assessing nutritional status and progress.

Observing meals: The nurse should focus on observing meals to ensure the client is eating properly and not engaging in behaviors such as pocketing food or spitting it out, which are common in clients with eating disorders.

A. Replace the indwelling urinary catheter. B. Perform the Credés maneuver. C. Maintain the irrigation solution rate. D. Warm the irrigation solution.

Correct Answer is C

Explanation

A. There is no need to replace the catheter unless it is obstructed or malfunctioning.

B. Credé’s maneuver is used for bladder emptying, not for continuous bladder irrigation.

C. Pink-tinged urine is expected in the first 24 hours after a transurethral resection of the prostate (TURP). The nurse should maintain the irrigation rate to prevent clot formation.

D. Warming the irrigation solution is not indicated.

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A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client on an acute mental health unit. Exhibits Complete the following sentence by using the list of options. The nurse should delegate the client's ____________ and focus on _________

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.