The prenatal clinic nurse is monitoring women for preeclampsia.
If all four women were in the clinic at the same time, which one should the nurse see first?
A dipstick value of 3+ for protein in her urine.
Pitting pedal edema at the end of the day.
Blood pressure increase to 138/86 mm Hg.
Weight gain of 0.5 kg during the past 2 weeks.
The Correct Answer is A
Choice A rationale
A dipstick value of 3+ for protein in the urine is a significant indicator of proteinuria, a key diagnostic criterion for preeclampsia. Preeclampsia is characterized by new-onset hypertension and proteinuria or other signs of end-organ damage in a previously normotensive pregnant woman. A 3+ protein level suggests substantial protein spillage into the urine, necessitating immediate attention to assess the severity of preeclampsia and prevent potential complications for both the mother and the fetus. Normal urine protein is typically negative to trace amounts.
Choice B rationale
Pitting pedal edema at the end of the day can be a common finding in pregnancy due to increased blood volume and pressure on the veins in the legs. While edema can be associated with preeclampsia, it is not a primary diagnostic criterion and can occur in normal pregnancies. Therefore, isolated pedal edema without other signs of preeclampsia is less concerning than significant proteinuria.
Choice C rationale
A blood pressure reading of 138/86 mm Hg is mildly elevated and falls within the range for stage 1 hypertension. While hypertension is a diagnostic criterion for preeclampsia, this isolated reading without a significant increase from baseline or other preeclampsia symptoms may not be the most urgent concern compared to significant proteinuria. Preeclampsia diagnosis requires a blood pressure of ≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman.
Choice D rationale
A weight gain of 0.5 kg (approximately 1.1 pounds) over two weeks is within the expected range for weight gain during pregnancy. While rapid or excessive weight gain can be a sign of fluid retention associated with preeclampsia, a modest gain of 0.5 kg over two weeks is not a primary indicator of the condition and is less concerning than significant proteinuria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Maintaining a patent airway is the immediate priority in the event of a seizure associated with eclampsia. During a seizure, the client's respiratory muscles may become compromised, leading to airway obstruction and hypoxemia, which can be detrimental to both the mother and the fetus. Ensuring a clear airway allows for adequate oxygenation.
Choice B rationale
While administering oxygen is important in managing eclampsia to address potential hypoxemia, establishing and maintaining a clear airway takes precedence. Without a patent airway, supplemental oxygen delivery will be ineffective. Oxygen administration typically follows ensuring airway patency.
Choice C rationale
Assessing blood pressure and fetal heart rate is crucial in monitoring the progression of preeclampsia and eclampsia, but it is not the immediate first action during an eclamptic seizure. The immediate concern is the client's airway and preventing injury during the seizure. Monitoring follows stabilization of the airway.
Choice D rationale
Magnesium sulfate is the medication of choice to prevent and treat eclamptic seizures. However, during an active seizure, the immediate priority is to ensure the client's safety and airway. Magnesium sulfate administration would follow the initial steps of airway management and seizure precautions.
Correct Answer is D
Explanation
Choice A rationale
The ventrogluteal muscle, located in the hip, is a safe site for intramuscular injections in adults and children older than seven months due to its distance from major nerves and blood vessels. However, the vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns and infants due to its well-developed muscle mass and accessibility.
Choice B rationale
The deltoid muscle, located in the upper arm, is small and not well-developed in newborns, making it an unsuitable site for intramuscular injections. There is also a risk of injury to the brachial nerve and blood vessels in this area in neonates.
Choice C rationale
The dorsogluteal muscle, located in the buttocks, is no longer the recommended site for intramuscular injections in infants and young children due to the proximity of the sciatic nerve and major blood vessels, increasing the risk of nerve damage.
Choice D rationale
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the recommended site for intramuscular injections in newborns. It is a large, well-developed muscle that is easily accessible and away from major nerves and blood vessels, making it a safe and effective site for administering vitamin K to prevent hemorrhagic disease of the newborn.
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