The nurse is continuing to care for the client.
seizures
hypoglycemia
cervical insufficiency
heart failure
placental abruption
Correct Answer : A,E
Rationale for Correct Choices
• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.
• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.
Rationale for Incorrect Choices
• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.
• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.
• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Change the drainage tubing every 48 hr: Routine changing of drainage tubing is not recommended unless it becomes contaminated or occluded. Frequent manipulation increases the risk of infection and compromises the sterile system.
B. Irrigate the drain to maintain suction: Irrigating a closed wound drainage system can introduce pathogens and disrupt the vacuum, increasing the risk of infection. Closed systems are designed to maintain suction without routine irrigation.
C. Observe for drainage flow through the tubing: Monitoring the amount, color, and consistency of drainage is essential to assess wound healing and detect complications such as infection or hemorrhage. Observing flow ensures the system is functioning properly and provides critical data for clinical decisions.
D. Remove the drain if output from the drain increases: Increased output can indicate ongoing bleeding or infection and should be reported to the provider. Premature removal of the drain in this situation could lead to fluid accumulation, wound dehiscence, or infection.
Correct Answer is D
Explanation
Rationale:
A. WBC count: A WBC of 13,000/mm³ is within the expected range for pregnancy, as mild leukocytosis commonly occurs due to physiologic changes, and does not require immediate reporting.
B. Fundal height: A fundal height of 27 cm at 29 weeks is slightly below average but may reflect individual variation, fetal position, or maternal factors. This finding warrants monitoring but is not an urgent concern.
C. Fetal heart rate: FHR of 158/min is within the normal range (110–160/min) for a fetus and does not indicate fetal distress, so immediate reporting is not necessary.
D. Hemoglobin: Hemoglobin of 10 g/dL is below the expected range for pregnancy (typically 11–16 g/dL). This indicates anemia, which can affect maternal and fetal oxygenation, making it important to report to the provider for further evaluation and management.
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