A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Grand mal seizure. The gravid client's presentation with 4+ proteinuria and 4+ reflexes indicates a severe condition known as preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, often the kidneys and liver. Preeclampsia puts the client at high risk for eclampsia, a more severe condition marked by seizures. Therefore, close monitoring for the development of seizures is crucial in this situation to prevent serious complications for both the mother and the fetus. Option B) High platelet count is incorrect because in preeclampsia, platelet count tends to decrease, leading to a risk of bleeding disorders rather than high platelet counts. Option C) Explosive diarrhea is not directly associated with the signs and symptoms of preeclampsia. While gastrointestinal issues can occur in some cases, they are not a primary concern in the context of a client presenting with significant proteinuria and reflex changes. Option D) Fractured pelvis is unrelated to the client's condition of preeclampsia. This option introduces a physical injury concern, which is not relevant to the client's current medical condition. Educationally, understanding the signs and symptoms of preeclampsia and its potential complications is critical for healthcare providers caring for pregnant clients. Timely recognition and appropriate management of conditions like preeclampsia can significantly impact maternal and fetal outcomes. Close monitoring and prompt intervention are essential in the care of pregnant clients at risk for developing complications like seizures in the context of preeclampsia.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Headache and decreased output. This symptom combination could indicate preeclampsia, a serious condition characterized by high blood pressure and organ damage. Teaching the client to watch for these signs is crucial for early detection and intervention. Option B) Puffy feet is a common occurrence in pregnancy due to fluid retention and is not necessarily a cause for immediate concern unless accompanied by other symptoms like high blood pressure. Option C) Hemorrhoids and vaginal discharge are common discomforts in pregnancy but are not typically indicators of a serious complication in the second half of pregnancy that would require immediate attention. Option D) Backache is a common complaint during pregnancy and is usually related to postural changes and the growing uterus pressing on nerves and muscles. While discomforting, it is not typically a sign of a complication that requires immediate medical attention. Educationally, this question highlights the importance of patient education in recognizing warning signs for potential complications during pregnancy. Teaching pregnant clients to be aware of specific symptoms and when to seek medical advice can help in the early detection and management of maternal diseases, ultimately improving outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In caring for an infant born with myelomeningocele, the highest priority nursing intervention is to protect the sac from injury (Option A). This is crucial to prevent infection and further damage to the exposed spinal cord. By covering the sac with a sterile, moist, non-adherent dressing, the risk of infection is minimized, and the infant is protected from trauma. Option B, preparing the parents for the child's paralysis, is important but not the highest priority at this moment. The immediate focus should be on protecting the sac to prevent complications. Option C, preparing for sac closure at around 2 years of age, is a valid intervention but is not the most urgent in the immediate postnatal period. Option D, assessing for cyanosis, is not directly related to the immediate care needed for a newborn with myelomeningocele. Educationally, understanding the critical nature of protecting the sac in infants with myelomeningocele highlights the importance of early intervention to prevent complications. Nurses play a vital role in educating parents and providing hands-on care to ensure the best outcomes for these vulnerable infants. By prioritizing sac protection, nurses can contribute significantly to the infant's well-being and long-term health.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Cardiac disease may demonstrate signs and symptoms of respiratory illness. This statement is correct because congenital anomalies of the cardiovascular system can often present with symptoms that mimic respiratory issues. Due to the close anatomical and functional relationship between the heart and lungs, cardiac abnormalities can lead to respiratory distress or symptoms, making it crucial to consider cardiac conditions in infants presenting with respiratory symptoms. Option B is incorrect because screening for congenital anomalies of the respiratory system should be comprehensive and not limited to only those infants experiencing respiratory distress. Early detection through routine screening is essential to identify and manage these anomalies effectively. Option C is incorrect because choanal atresia, a nasal cavity obstruction, typically requires a surgical intervention such as a choanoplasty, rather than simple removal using a suction catheter. Option D is incorrect as congenital diaphragmatic hernias are often diagnosed prenatally through imaging studies and require urgent management immediately after birth to prevent serious respiratory and cardiovascular complications. In an educational context, understanding the interconnectedness of the cardiovascular and respiratory systems in infants is crucial for healthcare professionals involved in the care of neonates. Recognizing the potential overlap of symptoms and the need for comprehensive screening and timely interventions are essential to improve outcomes for infants with congenital anomalies.

Correct Answer: A

Rationale: The correct answer is A) Mild cases involve a single surgical procedure. Rationale: - The nurse should inform the parents that mild cases of hypospadias often only require a single surgical procedure to correct the penile abnormality. This information reassures the parents that the condition can be effectively treated with a relatively straightforward procedure. Why the other options are incorrect: - Option B) Infant should be circumcised: Circumcision is not a treatment for hypospadias. It is a separate procedure and should not be confused with the surgical correction of hypospadias. - Option C) Repair is performed as soon as possible after birth: While early correction is recommended to prevent potential complications, the urgency of the surgery may vary based on the severity of the condition and the overall health of the newborn. - Option D) No correlation exists between hypospadias and testicular cancer: This statement is irrelevant to the immediate concerns of the parents regarding the treatment and management of hypospadias in their newborn. Educational context: - It is crucial for nurses to provide accurate and clear information to parents of newborns with congenital conditions like hypospadias. By understanding the treatment options and outcomes, parents can make informed decisions and feel more empowered to support their child through the necessary medical interventions. This education helps alleviate anxiety and fosters trust in the healthcare team.