The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?

Correct Answer: A

Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.

Correct Answer: B

Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.

Correct Answer: C

Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.

Correct Answer: B

Rationale: Duplex venous ultrasonography is the most accurate tool for assessing and diagnosing venous thrombosis. It is a non-invasive imaging technique that combines Doppler flow studies with conventional ultrasonography. This allows for the visualization of blood flow in the veins and identification of any blood clots or obstructions. Duplex venous ultrasonography is highly sensitive and specific for detecting deep vein thrombosis (DVT) in the lower extremities, making it the preferred imaging modality for diagnosing venous thrombosis. Other imaging modalities like ascending contrast venography, magnetic resonance imaging, and plethysmography are less commonly used due to their disadvantages compared to duplex venous ultrasonography such as invasiveness, cost, and lower accuracy.

Correct Answer: D

Rationale: Vomiting can lead to dehydration and electrolyte imbalances due to the loss of fluids and electrolytes. In response to these physiologic changes caused by vomiting, aldosterone secretion will increase. Aldosterone is a hormone produced by the adrenal glands that acts on the kidneys to increase reabsorption of sodium and water, helping to maintain blood pressure and electrolyte balance. By increasing aldosterone secretion, the body aims to retain more sodium and water to counteract the effects of vomiting and prevent dehydration.