The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

Seizures.

Stroke.

Organ damage.

Preterm birth.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Seizures can occur due to severe preeclampsia, leading to eclampsia, characterized by generalized tonic-clonic seizures. Magnesium sulfate is often used to prevent seizures in these patients, alongside other monitoring measures.

Choice B rationale

Stroke risk is elevated in preeclamptic patients due to hypertension, endothelial dysfunction, and increased coagulation. Blood pressure control is essential to reduce stroke risk and manage preeclampsia complications effectively.

Choice C rationale

Organ damage, particularly to the liver and kidneys, is a complication of preeclampsia. Elevated liver enzymes and proteinuria indicate hepatic and renal involvement, necessitating close monitoring and potential intervention to mitigate damage.

Choice D rationale

Preterm birth is often a result of preeclampsia due to placental insufficiency and maternal health deterioration. Early delivery may be necessary to protect the well-being of both mother and fetus, highlighting the importance of timely diagnosis.

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Correct Answer is C

Explanation

Choice A rationale

Phytonadione (vitamin K1) is not administered to improve dietary intake. Newborns receive it to prevent vitamin K deficiency bleeding, as they have low levels of vitamin K at birth due to limited placental transfer.

Choice B rationale

Phytonadione does not stimulate the immune system. It is a fat-soluble vitamin essential for the synthesis of clotting factors, which prevents bleeding disorders in newborns.

Choice C rationale

Newborns are given phytonadione to prevent hemorrhagic disorders, which can occur due to their immature liver's inability to produce sufficient clotting factors without adequate vitamin K.

Choice D rationale

While phytonadione supports liver function indirectly by aiding clotting factor synthesis, its primary role is to prevent hemorrhagic disease of the newborn, not directly to help an immature liver develop.

A. Evaluate fetal heart rate and contraction patterns. B. Obtain prescription to repeat hepatic panel. C. Monitor for evidence of seizure activity. D. Check the urinary output in hourly urinometer. E. Inspect the perineum for vaginal bleeding.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Evaluating fetal heart rate and contraction patterns is critical as magnesium sulfate can impact uterine activity and fetal well-being. Monitoring ensures timely intervention if abnormalities in fetal status or labor progression are detected.

Choice B rationale

Obtaining a prescription to repeat the hepatic panel is necessary to monitor liver function, especially if there is a suspicion of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) which complicates severe preeclampsia.

Choice C rationale

Monitoring for evidence of seizure activity is crucial as the patient is receiving magnesium sulfate for eclampsia prophylaxis. Close observation helps in early detection and management of any seizure episodes, preventing complications.

Choice D rationale

Checking urinary output in an hourly urinometer is essential to assess renal function, as preeclampsia and magnesium sulfate can affect renal perfusion and output. Monitoring ensures timely intervention if there is a decline in output.

Choice E rationale

Inspecting the perineum for vaginal bleeding is less immediately relevant unless there is a concern for placental abruption or other obstetric complications. Focus on maternal systemic symptoms and fetal monitoring is more critical initially.

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The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Correct Answer is C

Explanation

A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?