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. "Keep your feet together to provide a tight base of support": Incorrect. Keeping feet together reduces stability; a wide base of support is recommended.

B. "Keep objects away from your center of gravity while lifting": Incorrect. Objects should be kept close to the center of gravity to reduce strain.

C. "Bend at the waist when lifting objects from the floor": Incorrect. Bending at the knees, not the waist, is the correct technique to prevent back injury.

D. "Tighten abdominal muscles to improve balance": Tightening the abdominal muscles provides core stability and reduces the risk of injury when lifting.

A. Assess the IV for patency. B. Check the compatibility of cefazolin with the client's existing IV fluids. C. Review the client's allergy history. D. Obtain the reconstituted antibiotic from the pharmacy.

Correct Answer is C

Explanation

A. Assessing IV patency is important but comes after confirming the client is not allergic.

B. Checking compatibility ensures safe administration but is not the first priority.

C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.

D. Obtaining the medication is necessary but only after confirming it is safe for the client.

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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.