A woman who is 32 weeks pregnant presents to the clinic. The nurse suspects preeclampsia. Which of the following findings support this diagnosis? (Select All that Apply.)

Mild fatigue after walking

Mild headache with blurred vision

150/95 mmHg blood pressure

Sudden weight loss

+2 protein in the urine

Answer and Explanation

Correct Answer : B,C,E

A. Mild fatigue after walking is a common symptom in normal pregnancy and is not specific to preeclampsia. Fatigue alone does not indicate hypertension or organ involvement.

B. Headache with blurred vision is a classic symptom of preeclampsia, indicating possible cerebral involvement due to elevated blood pressure and vasospasm. Persistent or severe headache should always be evaluated in the context of preeclampsia.

C. Blood pressure ≥140/90 mmHg after 20 weeks gestation in a previously normotensive woman is one of the diagnostic criteria for preeclampsia. This patient’s reading of 150/95 mmHg supports the diagnosis.

D. Sudden weight loss is not a feature of preeclampsia. On the contrary, rapid weight gain due to fluid retention is often seen in preeclampsia.

E. Proteinuria (+1 or higher on a urine dipstick or ≥300 mg/24 hours) is another hallmark of preeclampsia. +2 proteinuria indicates significant renal involvement, supporting the diagnosis.

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Correct Answer is C

Explanation

A. Fever is a common symptom of RSV, and antipyretics can improve comfort. However, fever itself is not life-threatening and does not directly address the risk of airway compromise or hypoxia. Therefore, antipyretics are secondary to interventions that support breathing and oxygenation.

B. Hydration is important because RSV can cause poor oral intake, dehydration, and increased mucus viscosity, which may worsen airway obstruction. While promoting fluids is necessary, it is not as urgent as ensuring adequate oxygenation.

C. Continuous monitoring of oxygen saturation allows for early detection of hypoxemia. Hypoxia can develop rapidly in infants and toddlers with RSV due to their smaller airway size and limited respiratory reserve. Humidified oxygen helps maintain airway moisture, reduces airway irritation, and supports gas exchange. Ensuring adequate oxygenation prevents complications such as respiratory failure, apnea, or cardiac compromise, making it the highest priority intervention.

D. RSV is highly contagious and spreads via respiratory droplets and direct contact. Precautions are essential to protect staff and other patients, but infection control measures do not address the immediate threat to the patient’s respiratory status. Priority interventions must first ensure the child’s airway and oxygenation are stable.

A. Apply a cold compress to the wound B. Encourage the child to ambulate to prevent stiffness C. Provide a tetanus booster and tetanus immune globulin D. Administer oral antibiotics

Correct Answer is C

Explanation

A. While cold compresses can reduce local pain and inflammation, they do not address the systemic risk of tetanus. Given the child’s symptoms (stiff jaw, muscle spasms, difficulty swallowing) 10 days after stepping on a rusty nail, tetanus is suspected, and simply treating the wound locally is insufficient.

B. Muscle stiffness and spasms in tetanus are caused by neurotoxin effects on the nervous system, not inactivity. Ambulation does not prevent the progression of tetanus and could increase the risk of falls or injury.

C. The child’s clinical presentation is consistent with tetanus, which is a medical emergency. The priority intervention is to neutralize the toxin and provide active and passive immunization. The tetanus booster stimulates active immunity, while tetanus immune globulin (TIG) provides immediate passive immunity to neutralize circulating toxin. This intervention is life-saving and takes priority over local wound care or antibiotics.

D. Antibiotics like metronidazole or penicillin are used to reduce bacterial load, but they do not neutralize circulating tetanus toxin and are secondary to immediate immunotherapy. Delaying TIG while focusing only on antibiotics could be fatal.

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A woman who is 32 weeks pregnant presents to the clinic. The nurse suspects preeclampsia. Which of the following findings support this diagnosis? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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