The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?
1. Excretion of less than 300 mg of protein in a 24-hour period
2. Platelet count of less than 100,000/mm3
3. Urine output of 50 mL per hour
4. 12 respirations
2
Explanation: 2. HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) complicates 10% to 20% of severe preeclampsia cases and develops prior to 37 weeks' gestation 50% of the time. Vascular damage is associated with vasospasm, and platelets aggregate at sites of damage, resulting in low platelet count (less than 100,000/mm3).
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The nurse is examining a client who is 37 weeks pregnant. Which assessment finding would require immediate intervention by the nurse?
1. Patellar reflex 4+/0 - 4+ bilaterally. 2. Heart rate 104. 3. Trace protein in the urine. 4. Weight gain of two pounds in 2 months.
Mr. Gonzalez is scheduled to undergo a hip replacement after he slipped on an icy step. During the preoperative phase, the nurse begins to enter the assessment findings into the database
Which of the following standardized terminologies will the nurse most likely use? 1. The Omaha System 2. The PeriOperative Nursing Data Set (PNDS) 3. North American Nursing Diagnosis International (NANDA-I) 4. International Classification of Nursing Practice (ICNP)
The nurse is caring for a multipara woman during labor who has requested an epidural block. The nurse will tell the patient that the epidural block will be given when her cervix is dilated
a. 1 to 2 cm. b. 3 to 4 cm. c. 5 to 6 cm. d. 7 to 8 cm.
Non-pharmacological therapy, including the administration of substances such as water and lactose, is known as:
a. fluid therapy. b. nutritional therapy. c. biofeedback therapy. d. placebo therapy.