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
Following a dilation and curettage (D&C) for a spontaneous miscarriage, the uterus needs time to heal. Resuming vaginal intercourse after approximately 2 weeks allows for some initial healing of the uterine lining and helps reduce the risk of infection. Healthcare providers typically advise waiting until bleeding has significantly decreased and discomfort has subsided.
Choice B rationale
While adequate nutrition is important for overall recovery after a miscarriage, there is no specific recommendation to increase the intake of zinc-rich foods in particular. A balanced diet supporting tissue repair is generally advised.
Choice C rationale
Aspirin is a salicylate and has antiplatelet properties. It is generally not recommended for managing cramps after a D&C due to the increased risk of bleeding. Acetaminophen or ibuprofen are typically preferred for pain relief.
Choice D rationale
Following a D&C for a spontaneous miscarriage, the products of conception have been removed from the uterus. While some vaginal bleeding is expected as the uterus heals, it should not contain identifiable fetal or placental tissue. Persistent passage of such tissue could indicate an incomplete evacuation or other complications requiring medical attention. .
Correct Answer is D
Explanation
Choice A rationale
Hydralazine is an antihypertensive medication used to manage hypertension, not preterm labor. Administering hydralazine would be inappropriate for a client in preterm labor unless she also has hypertension.
Choice B rationale
Preparing the client for immediate delivery based solely on a lecithin-to-sphingomyelin (L/S) ratio of 1: is premature. An L/S ratio of 2: or greater is generally indicative of fetal lung maturity. A ratio of 1: suggests lung immaturity, and interventions to promote lung maturity are indicated.
Choice C rationale
Infusing a bolus of IV fluids might be considered for hydration in preterm labor, but it does not directly address the issue of fetal lung immaturity indicated by the low L/S ratio. While hydration can help manage preterm contractions in some cases, it is not the primary intervention to improve fetal lung maturity.
Choice D rationale
Administering betamethasone, a corticosteroid, is the appropriate action for a client in preterm labor with a low L/S ratio (1:). Betamethasone crosses the placenta and stimulates the production of surfactant in the fetal lungs, accelerating lung maturity and reducing the risk of respiratory distress syndrome in the preterm infant. The typical dose is 12 mg IM, given in two doses 24 hours apart. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.