A nurse is caring for a client who is pregnant.
The nurse is reviewing the client's medical record.
Select 4 findings that indicate a potential prenatal complication.
Urine protein.
Blood pressure.
Respiratory rate.
Report of headache.
Gravida/parity.
Fetal activity.
Urine ketones.
Correct Answer : A,B,D,F
The correct answer is choice A, B, D, and F.
Choice A rationale:
The presence of protein in the urine (proteinuria) is a sign of potential prenatal complication. Normally, urine should be protein negative. Proteinuria can be a sign of preeclampsia, a serious condition that includes high blood pressure and swelling, and can lead to preterm birth or other serious complications if not managed.
Choice B rationale:
The client’s blood pressure is 162/112 mm Hg, which is significantly higher than the normal range (less than 120/80 mm Hg). High blood pressure during pregnancy could indicate preeclampsia or other complications.
Choice C rationale:
The client’s respiratory rate is 16/min, which falls within the normal range (12-20 breaths per minute). Therefore, it does not indicate a potential prenatal complication.
Choice D rationale:
The client’s report of a severe headache unrelieved by acetaminophen is concerning. This could be a symptom of preeclampsia or other serious conditions and should be investigated further.
Choice E rationale:
The client’s gravida/parity (G3 P2 with one preterm birth) does not directly indicate a potential prenatal complication. However, a history of preterm birth could put the client at higher risk for another preterm birth.
Choice F rationale:
The client’s report of decreased fetal movement is concerning. Decreased fetal movement can be a sign of fetal distress or other complications and should be investigated further.
Choice G rationale:
The client’s urine does not contain ketones, which would indicate that the body is using fat for energy instead of glucose. This could occur in cases of poor nutrition or gestational diabetes. Since the urine is ketone negative, this does not indicate a potential prenatal complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.
Choice B rationale:
A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.
Choice C rationale:
A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.
Choice D rationale:
Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.
Correct Answer is C
Explanation
Choice A rationale:
Soaking in a warm bath every day is not a preventative measure for chronic urinary tract infections. Warm baths might provide temporary relief for discomfort but do not prevent UTIs.
Choice B rationale:
Taking an oral estrogen supplement is not a standard preventative measure for chronic urinary tract infections. Estrogen therapy might be recommended for postmenopausal women with recurrent UTIs, but it's not a general preventive method for all women.
Choice C rationale:
"Drink 2 liters of water per day." This is the correct answer. Staying well-hydrated is essential to prevent urinary tract infections. Drinking an adequate amount of water can help flush out bacteria from the urinary system, reducing the risk of infections. The normal range for daily water intake varies but is generally around 2-3 liters or eight 8-ounce glasses per day.
Choice D rationale:
Emptying the bladder every 6 hours is a good practice, but it might not be sufficient for someone prone to chronic UTIs. Regular and frequent urination can help prevent the buildup of bacteria in the urinary tract. However, specific time intervals might vary from person to person, so a fixed 6-hour rule might not apply to everyone.
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