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    Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph
    Select All That Apply

    A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

    Explanation & Rationale

    A. Decreased fetal movement is a warning sign of fetal distress or compromised fetal well-being. It may indicate insufficient oxygenation or nutrient delivery due to placental insufficiency, which can occur in complications such as preeclampsia or intrauterine growth restriction. Immediate assessment, such as a non-stress test (NST) or continuous fetal monitoring, is warranted. B. A severe headache in the third trimester, especially unrelieved by acetaminophen, is a classic symptom of preeclampsia. This occurs due to elevated blood pressure causing cerebral vasospasm or edema. Persistent headache may precede more severe manifestations like visual disturbances, hyperreflexia, or seizures (eclampsia). C. Trace or mild ketones in urine can occur due to fasting, dehydration, or high metabolic demand during pregnancy. While monitoring is important, in the absence of significant hyperglycemia or diabetic ketoacidosis, urine ketones alone do not indicate an acute prenatal complication. D. Proteinuria (3+) is one of the diagnostic criteria for preeclampsia. It reflects glomerular injury caused by endothelial dysfunction in hypertensive disorders of pregnancy. Persistent proteinuria combined with high blood pressure requires close monitoring and intervention to prevent maternal and fetal complications. E. Elevated BP (162/112 mm Hg) is severe and meets the criteria for preeclampsia (≥140/90 mm Hg). Uncontrolled hypertension in pregnancy increases the risk of stroke, placental abruption, fetal growth restriction, and maternal organ damage. Blood pressure must be monitored closely, and antihypertensive therapy may be indicated. F. Gravida (G3) and parity (P2) provide obstetric history but do not indicate a current complication. High parity may increase risk in general, but it is not an immediate clinical concern for acute prenatal issues. G. A respiratory rate of 16/min is within normal limits for adults and pregnant women. It does not indicate acute compromise or prenatal complication.

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