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A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record.

Exhibits
Select 4 findings that indicate a potential prenatal complication

Blood pressure

Urine ketones

Fetal activity

Respiratory rate

Report of headache

Urine protein

Gravida/parity

Answer and Explanation

Correct Answer : A,C,E,F

Rationale:

A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.

B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.

C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.

D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.

E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).

F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.

G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.

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Correct Answer is A

Explanation

Rationale:

A. Consult the pharmacist about potential interactions between the client's regular medications and warfarin: Warfarin has numerous drug interactions that can increase bleeding risk or reduce effectiveness. Consulting the pharmacist ensures a thorough review of the client’s medication list for potential harmful interactions before discharge.

B. Tell the client they can continue to drink cranberry juice while taking warfarin: Cranberry juice can potentiate the effects of warfarin and increase bleeding risk by interfering with its metabolism. Clients should be advised to limit or avoid cranberry products.

C. Recommend the client take warfarin at the same time as other medications: Warfarin should be taken at the same time each day, but taking it with other medications may cause interactions. The timing should consider spacing it from medications that might interfere with absorption or potency.

D. Advise the client that over-the-counter medications remain safe to consume as needed: Many OTC medications, especially NSAIDs, can increase bleeding risk when combined with warfarin. Clients need to check with a healthcare provider before taking any new OTC drugs.

A. "I will remove gluten from my diet.” B. "I will remove peanuts from my diet.” C. "I will remove bananas from my diet. D. "I will remove dairy products from my diet."

Correct Answer is C

Explanation

Rationale:

A. "I will remove gluten from my diet.": Gluten is unrelated to latex allergies. It is typically avoided in conditions like celiac disease, but does not cross-react with latex proteins and is not a concern for latex-sensitive individuals.

B. "I will remove peanuts from my diet.": Although peanut allergies are common, there is no significant cross-reactivity between peanuts and latex. Avoiding peanuts is not necessary unless the client has a separate peanut allergy.

C. "I will remove bananas from my diet.": Bananas contain proteins similar to those found in natural latex. Clients with latex allergies often have cross-reactive food allergies, especially to bananas, avocados, kiwis, and chestnuts this is known as latex-fruit syndrome.

D. "I will remove dairy products from my diet.": Dairy products are not associated with latex sensitivity. Removing them offers no protective benefit for clients with a latex allergy unless a separate dairy intolerance or allergy exists.

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A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record. Exhibits Select 4 findings that indicate a potential prenatal complication

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A nurse is caring for a client who is pregnant. The nurse is reviewing the client's medical record.

Exhibits
Select 4 findings that indicate a potential prenatal complication