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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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

  • Minimize environmental stimuli for the client: This is appropriate because clients experiencing acute mania are highly distractible and overstimulated. A low-stimulation environment helps reduce agitation and promotes safety.
  • Weigh the client each day: Daily weights are necessary as manic clients often exhibit decreased nutritional intake and increased physical activity, placing them at risk for weight loss and dehydration.
  • Provide the client with high-calorie fluids every hour: Frequent intake of calorie-dense fluids supports the client’s nutritional needs without requiring prolonged focus or interruption of hyperactive behavior.
  • Encourage the client to avoid napping during the day: This is contraindicated because rest is crucial during manic episodes. Encouraging naps supports mood stabilization and prevents exacerbation of manic symptoms due to sleep deprivation.

Correct Answer is D

Explanation

A. Sacrum: The sacrum is typically assessed for pressure injuries but is not the most reliable site for detecting cyanosis in clients with dark skin because of variable pigmentation.
B. Shoulders: The shoulders have significant pigmentation and are not ideal for assessing cyanosis in dark-skinned clients due to difficulty distinguishing color changes.
C. Area of trauma: Trauma sites may show redness or bruising unrelated to cyanosis, making them unreliable for assessing oxygenation status.
D. Palms of the hands: The palms have less melanin and are lighter in color, making them a better site to observe for cyanosis in clients with dark skin due to clearer visualization of bluish discoloration.

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