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 B

Explanation

A. Flumazenil is used for benzodiazepine overdose, not opioid overdose.

B. Naloxone is the antidote for opioid overdose and is indicated here due to the low respiratory rate and recent administration of hydromorphone.

C. Acetylcysteine is used for acetaminophen overdose, not opioids.

D. Protamine is used to reverse heparin, not opioids.

A. Schedule the client for retesting in 1 week. B. Administer ceftriaxone via intermittent IV bolus. C. Instruct the client to abstain from sexual intercourse for 1 month. D. Report the infection to the state department of health.

Correct Answer is D

Explanation

A. Schedule the client for retesting in 1 week: Retesting is typically done after 3 months, not 1 week.

B. Administer ceftriaxone via intermittent IV bolus: Ceftriaxone is used for gonorrhea, not chlamydia.

C. Instruct the client to abstain from sexual intercourse for 1 month: Abstinence is recommended until treatment is completed and partners are treated, not necessarily for 1 month.

D. Report the infection to the state department of health: Reporting is required by law to help track and reduce the spread of STIs.

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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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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.