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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

as evidenced by the client's.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Rationale for Correct Options:

  • Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
  • Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

  • Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
  • Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
  • Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
  • Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.


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Related Questions

Correct Answer is A

Explanation

A. Reposition the client sideways each hour: Repositioning helps prevent pressure injuries, promotes even distribution of the anesthetic, and reduces the risk of unilateral block or venous stasis, which is especially important after epidural placement.
B. Have protamine sulfate available at the bedside: Protamine sulfate is an antidote for heparin, not epidural anesthesia. It has no role in managing side effects or complications related to an epidural.
C. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to vasodilation. The nurse should monitor for low blood pressure, not elevated readings.
D. Decrease the maintenance infusion rate of IV fluid: IV fluids are often increased prior to and after epidural placement to counteract potential hypotension. Reducing the rate could worsen the risk of low blood pressure.

Correct Answer is A

Explanation

A. Ask the client if they would prefer a translator who is the same gender: Cultural sensitivity includes acknowledging gender preferences in healthcare interactions. Offering a choice respects the client’s values and supports effective, respectful communication.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained staff or students as interpreters can lead to errors or breaches in confidentiality. Only qualified medical interpreters should be used to ensure accuracy and professionalism.
C. Use a website with a ".com" URL to translate for the client: Online translation tools are not reliable for medical communication. They can lead to serious misunderstandings and are not appropriate for clinical use.
D. Request a family member of the client to translate: Family members may lack the language skills or medical knowledge to translate accurately and may filter or misinterpret information. This can compromise informed consent and patient safety.

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