The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern?

Correct Answer: C

Rationale: In a pregnant woman, a hematocrit level of 24% is cause for concern as it is lower than the normal range during pregnancy. A lower than normal hematocrit level may indicate anemia in the pregnant woman, which can lead to complications for both the mother and the baby. Anemia during pregnancy can result in inadequate oxygen reaching the tissues, fatigue, increased risk of preterm birth, and low birth weight for the baby. Therefore, this finding should be further evaluated and managed promptly to ensure the well-being of the pregnant woman and her baby.

Correct Answer: A

Rationale: The most common clinical manifestation of coronary artery disease is chest pain, also known as angina pectoris. This pain is typically described as a pressure, squeezing, tightness, or heaviness in the chest that may radiate to the arms, neck, jaw, shoulders, or back. It is usually triggered by physical exertion or emotional stress and is relieved by rest or medications such as nitroglycerin. Chest pain occurs due to reduced blood flow to the heart muscles caused by atherosclerosis in the coronary arteries. While dyspnea (shortness of breath), irritability, and tachycardia (rapid heart rate) can also be associated with coronary artery disease, chest pain is the hallmark symptom that often prompts individuals to seek medical attention for further evaluation.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Correct Answer: A

Rationale: Morning headaches that extend into the neck and subside as the day progresses can be indicative of elevated blood pressure, which is a common cause of morning headaches. Increased blood pressure can cause headaches that are usually worse in the morning due to the body's natural circadian rhythms. Monitoring the client's blood pressure and assessing for other signs of hypertension would be important in this case. Tachycardia, otitis media, and swollen lymph nodes are less likely to be associated with the described symptoms.

Correct Answer: B

Rationale: In eclampsia, seizures can occur due to the underlying hypertensive crisis affecting the brain. A classic grand mal seizure consists of two phases: the tonic phase and the clonic phase. During the tonic phase, there is a sudden loss of consciousness and muscle tone, leading to the person falling down. The clonic phase follows the tonic phase and is characterized by rhythmic, repetitive muscle contractions and relaxation. Therefore, the accurate statement about the characteristics of a grand mal seizure in the context of eclampsia is that the clonic phase is evidenced by muscular contraction and rigidity.