Nokea
The client at 32 weeks’ gestation presents to a hospital with a severe headache. Her admission BP is 184/104 mm Hg. Based on the assessment and findings of the serum laboratory report, which most severe complication warrants the nurse’s further assessment?
- A. Renal failure
- B. Liver failure
- C. Preeclampsia
- D. HELLP syndrome
Correct Answer: D
Rationale: It is most important for the nurse to further assess for HELLP syndrome, a variation of pregnancy-induced hypertension characterized by hemolysis (elevated bilirubin), elevated liver enzymes, and low platelets. The laboratory results do not show the serum creatinine level, so no inferences can be made about renal failure. Although liver enzymes are elevated, HELLP syndrome is a more severe complication associated with pregnancy. Preeclampsia commonly coexists with HELLP syndrome; however, these laboratory findings show worsening symptoms that are associated with HELLP syndrome.
You may also like to solve these questions
The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.
The nurse emphasizes which safety measure during prenatal education?
- A. Avoiding raw or undercooked meat
- B. Sleeping on the stomach throughout pregnancy
- C. Using saunas regularly
- D. Taking herbal supplements without consultation
Correct Answer: A
Rationale: Avoiding raw or undercooked meat prevents infections like toxoplasmosis, a key safety measure for fetal health.
The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, “Nothing, really. I’m not in pain or anything, but I just seem to cry a lot for no reason.” What should be the nurse’s first intervention?
- A. Call the client’s support person to come and sit with her.
- B. Remind her that she has a healthy baby and that she shouldn’t be crying.
- C. Contact the HCP to have the counselor come see the client.
- D. Ask the client to discuss her birth experience.
Correct Answer: D
Rationale: The client’s support person should be given information about postpartum blues before the client is discharged from the hospital. However, contacting that individual should not be the first intervention. Reminding the client that she has a healthy baby is a nontherapeutic communication technique that implies disapproval of the client’s actions. There is no need to notify the HCP, as postpartum blues is a common self-limiting postpartum occurrence. A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience.
The pregnant client presents to a clinic with ongoing nausea, vomiting, and anorexia at 29 weeks’ gestation. Her Hgb level is 5 g/dL, and a blood smear reveals that newly formed RBCs are macrocytic. Which condition should the nurse further explore?
- A. Sickle cell anemia
- B. Folic acid deficiency anemia
- C. Beta-thalassemia minor
- D. Beta-thalassemia major
Correct Answer: B
Rationale: With the client’s symptoms and laboratory findings, the nurse should further explore folic acid deficiency. It is usually seen in the third trimester and coexists with iron-deficiency anemia. Sickle cell anemia is an inherited disorder in which the Hgb is abnormally formed. The chief symptom among individuals with sickle cell anemia is pain. Beta-thalassemia minor is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule. Beta-thalassemia minor typically results in mild anemia. Beta-thalassemia major is an inherited hematological disorder. There is a defect in the synthesis of the beta chain within the Hgb molecule, but it is more severe than beta-thalassemia minor. Pregnancy in individuals with beta-thalassemia major is rare. Symptoms are usually severe anemia that warrants transfusion therapy.
The nurse explains to the group that frequent urination during early pregnancy usually subsides at which time?
- A. When the placenta is fully developed
- B. When fetal kidneys begin to function
- C. When the uterus rises into the abdominal cavity
- D. When the hormonal balance is reestablished
Correct Answer: C
Rationale: Frequent urination subsides in the second trimester as the uterus rises into the abdominal cavity, reducing bladder pressure.