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 D

Explanation

A. Breathing exercises involve inhaling through the nose and exhaling through the mouth for better oxygenation and relaxation.

B. Mindfulness focuses on being present and observing thoughts nonjudgmentally, not necessarily seeking advice from others.

C. Guided imagery involves imagining calming or peaceful scenarios, not stimulating ones.

D. Progressive muscle relaxation involves tensing and then relaxing muscle groups to relieve tension and promote relaxation.

A. Return in two weeks for a follow-up MRI. B. Expect to have a rapid pulse rate for the first few weeks. C. Wear loose-fitting clothing. D. Resume tub baths and swimming after 24 hr

Correct Answer is C

Explanation

A. Return in two weeks for a follow-up MRI: MRI is generally contraindicated for clients with ICDs unless the device is MRI-compatible.

B. Expect to have a rapid pulse rate for the first few weeks: ICDs do not cause a sustained rapid pulse rate.

C. Wear loose-fitting clothing: Loose clothing prevents irritation and promotes healing of the surgical site, reducing the risk of infection.

D. Resume tub baths and swimming after 24 hr: Clients should avoid soaking the surgical site until fully healed.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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.