The nurse is continuing to care for the client.
Nurses' Notes.
Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.
headache unrelieved by acetaminophen.
Client also reports.
urinary frequency and decreased fetal movement.
Client is a G3. P2 with one preterm birth.
Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.
+3. pitting edema in bilateral lower extremities.
Patellar reflex 4+. without the presence of clonus.
Client reports occasional.
nighttime leg cramps.
Reports three fetal movements within the.
last 30 min.
External fetal monitor applied with a baseline FHR.
140/min with occasional accelerations and moderate variability.
No uterine contractions noted.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Oxygen saturation 979% on room air.
Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 999% on room air.
Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). The nurse is reviewing the assessment findings.
For each assessment finding, click to specify if the finding is consistent with.
preeclampsia or HELLP syndrome.
Each finding may support more than one.
disease process.
Platelet count
Hemoglobin
Alanine aminotransferase (ALT)
Blood pressure
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Having the client exhale deeper than she inhales is a breathing technique that can help manage pain but does not specifically address the request for pain management techniques during natural childbirth. Option A does not provide comprehensive information about pain management strategies during labor.
Choice B rationale:
Providing information about the use of hydrotherapy during labor is a valid suggestion. Hydrotherapy, such as taking a warm bath or using a shower during labor, can help alleviate pain and promote relaxation. It is a non-pharmacological pain management option that the client can consider.
Choice C rationale:
Encouraging the client to have the family exit the room when the pain is unbearable may offer emotional support, but it does not provide a direct pain management technique. Additionally, the presence of loved ones can be a source of comfort for the client during labor.
Choice D rationale:
Informing the client that using pharmacological pain management will not impact the delivery is a true statement. Pharmacological pain relief methods, such as epidural anesthesia, do not affect the progress of labor or the outcome of delivery. However, this option does not provide an alternative pain management technique for the client who desires natural childbirth.
Correct Answer is C
Explanation
The correct answer isChoice C.
Choice A rationale:
Encouraging the client to drink low-protein supplements is not the best action. Protein is essential for tissue repair and healing, especially when the body is under stress, such as during radiation therapy. Therefore, it would be more beneficial to encourage high-protein foods and supplements.
Choice B rationale:
Serving the client’s largest meal in the evening is not the most effective strategy. Radiation therapy can cause nausea and vomiting, which are often worse later in the day. Therefore, it might be more beneficial to serve a larger meal earlier in the day when the client is more likely to tolerate it.
Choice C rationale:
Providing the client with cold foods rather than hot foods is the correct action. Hot foods can often exacerbate feelings of nausea, which are common side effects of radiation therapy.Cold foods are generally better tolerated.
Choice D rationale:
Telling the client to drink two glasses of water with meals is not the best advice. While hydration is important, drinking large amounts of fluid with meals can contribute to early satiety, which can further decrease the client’s food intake. It might be more beneficial to encourage the client to drink fluids between meals.
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