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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.

Fetal activity

Urine ketones

Urine protein

Report of headache

Respiratory rate

Blood pressure

Gravida/parity

Answer and Explanation

Correct Answer : A,C,D,F

Rationale:
A. Fetal activity: Decreased fetal movement is an abnormal finding suggesting possible fetal distress or hypoxia. It indicates reduced oxygen or nutrient delivery to the fetus, often associated with maternal complications such as hypertension or preeclampsia. Immediate evaluation with fetal monitoring or ultrasound is warranted.

B. Urine ketones: The absence of urine ketones is expected and does not indicate a prenatal complication. Ketones would only be concerning if elevated, as they could signal dehydration, starvation, or poorly controlled diabetes, which is not present in this case.

C. Urine protein: The presence of 3+ protein in the urine is a key indicator of preeclampsia. Proteinuria results from endothelial damage in the kidneys caused by hypertension, leading to leakage of protein into the urine and confirming a serious pregnancy complication.

D. Report of headache: A severe, persistent headache unrelieved by acetaminophen suggests cerebral vasospasm related to preeclampsia. It reflects increased blood pressure affecting cerebral circulation and can precede seizures or eclampsia if untreated.

E. Respiratory rate: A respiratory rate of 16/min is within the normal range for adults and does not indicate a prenatal complication. There is no evidence of respiratory distress or metabolic abnormality in this finding.

F. Blood pressure: A reading of 162/112 mm Hg meets the diagnostic criteria for severe hypertension in pregnancy and strongly indicates preeclampsia. Uncontrolled elevated blood pressure increases the risk of seizures, placental abruption, and fetal growth restriction.

G. Gravida/parity: Being G3 P2 with one preterm birth is useful background information but not, by itself, a sign of a current complication. It helps identify obstetric history and risk factors but does not reflect an immediate prenatal concern in this assessment.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.

B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.

C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.

D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.

A. Hypothermia B. Maternal diabetes C. Anemia D. Prematurity E. Thrombocytopenia

Correct Answer is ["A","B","D"]

Explanation

Rationale:
A. Hypothermia: Hypothermia increases metabolic demand and glucose utilization in newborns, making them more susceptible to hypoglycemia. Maintaining normal body temperature is crucial for preventing low blood glucose levels.

B. Maternal diabetes: Infants born to mothers with diabetes are at higher risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the excess insulin can cause rapid drops in blood glucose.

C. Anemia: While anemia affects oxygen-carrying capacity, it is not a direct risk factor for neonatal hypoglycemia. Blood glucose regulation is not primarily impacted by red blood cell count.

D. Prematurity: Premature infants have limited glycogen stores and immature glucose regulation, increasing the risk for hypoglycemia. They may require closer glucose monitoring and early feeding interventions.

E. Thrombocytopenia: Low platelet count does not affect glucose metabolism and is not a recognized risk factor for neonatal hypoglycemia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

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.