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. The condom should fit snugly but not just over the tip of the penis; it should cover the entire shaft.
B. Condoms provide protection against sexually transmitted diseases (STDs) and should be used in addition to implanted contraceptive methods (such as IUDs or implants) to prevent the spread of STDs. Implanted contraceptives do not offer STD protection.
C. Spermicides can increase condom effectiveness, but condoms are not equally effective with or without them. Their effectiveness varies.
D. Petroleum-based lubricants can degrade latex condoms and increase the risk of breakage, so water-based or silicone-based lubricants are recommended.

A. Obtain a surge protector that can accommodate the pump and several other appliances. B. Report the pump has a frayed cord and proceed with the infusion. C. Check the expiration date on the safety inspection sticker of the pump. D. Verify that the extension cord for the pump is ungrounded.

Correct Answer is C

Explanation

A. Using a surge protector with multiple appliances increases the risk of electrical overload and is not recommended.

B. A frayed cord poses a safety hazard and should be reported immediately; the infusion should not proceed.

C. The nurse should check the expiration date on the safety inspection sticker to ensure the infusion pump has passed recent safety inspections and is safe to use.

D. The extension cord must be grounded for safety; ungrounded cords increase the risk of electrical shock.

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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.