The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Swollen hands.

Headache.

Blurred vision.

Lack of appetite.

Chills and fever.

Urinary frequency.

Answer and Explanation

Correct Answer : A,B,C

A. Swollen hands can indicate edema, which is a common sign of preeclampsia. Swelling, especially in the hands, face, or feet, can be due to elevated blood pressure and should be reported to the healthcare provider.

B. Headaches are a concerning symptom in preeclampsia, especially when they are persistent or severe. This is often due to high blood pressure and requires medical evaluation to prevent complications like eclampsia or stroke.

C. Blurred vision is a serious indicator of preeclampsia as it reflects possible neurological involvement or increased blood pressure, which can affect blood flow to the brain and eyes. This is an urgent symptom that needs prompt medical attention.

D. Lack of appetite is not a common or specific symptom of preeclampsia. It may be present in other conditions, but it is not a key indicator of preeclampsia.

E. Chills and fever are typically associated with infections, not preeclampsia. These symptoms do not indicate the presence of preeclampsia and are unrelated to hypertensive disorders of pregnancy.

F. Urinary frequency is more commonly related to pregnancy in general due to the growing uterus pressing on the bladder. It is not specifically associated with preeclampsia. In preeclampsia, a decrease in urine output may be more concerning as it can signal kidney involvement.

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Free Nursing Study Resources

Correct Answer is ["A","F","G"]

Explanation

A. Increase the fractional concentration of Inspired oxygen: As the partial pressure of oxygen (PaO) has decreased to 64 mm Hg from 99 mm Hg, and the oxygen saturation may drop, it's necessary to increase the fraction of inspired oxygen (FiO2) to maintain adequate oxygenation.
B. Change the ventilator settings to continuous positive airway pressure (CPAP): CPAP is not typically used in patients who are intubated. CPAP is a non-invasive ventilation mode used for patients with respiratory distress who are breathing spontaneously. In this case, the patient is intubated and requires mechanical ventilation, so CPAP is not appropriate.
C. Increase the respiratory rate: While the respiratory rate has decreased from 15 to 13 breaths/minute, it's important to maintain a careful balance when adjusting ventilator settings. Increasing the respiratory rate may not be necessary at this point, especially if the patient is still oxygenating adequately. Moreover, the primary concern appears to be hypoxemia rather than hypoventilation.
D. Continue weaning the ventilator as ordered: While weaning the patient off the ventilator is a goal, it may not be appropriate at this time, especially with the worsening blood gas values
indicating respiratory insufficiency. Continuing the weaning process could potentially exacerbate respiratory failure.

E. Decrease the tidal volume: Decreasing the tidal volume could worsen ventilation-perfusion matching and exacerbate hypoxemia. This approach might be considered in certain cases of acute respiratory distress syndrome (ARDS) or in patients with severe lung injury, but it's not typically indicated in this scenario without further assessment.

F. Alert the provider of the blood gas values: The nurse should inform the provider about the changes in blood gas values, especially the decrease in PaO2 and the increase in PaCO2, which indicate worsening respiratory status and potential respiratory acidosis.

G. Switch the ventilator to pressure control: Given the deterioration in respiratory status with an increase in PaCO2 and decrease in PaO2, switching to pressure control ventilation may provide better control over the patient's ventilation and oxygenation, especially in cases of acute
respiratory failure.

A. Measure and record the client's urinary output every day. B. Obtain a blood pressure reading before the client gets out of bed. C. Obtain the client's vital signs every 4 hours when awake. D. Provide the client with teaching regarding a cardiac diet.

Correct Answer is B

Explanation

A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.

B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.

C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.

D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.

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The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Correct Answer is ["A","F","G"]

Explanation

Correct Answer is B

Explanation

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