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    RN Comprehensive Predictor Proctored Exam (National U CA San Diego)
    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

    Rationale: A. Fetal activity: Decreased fetal movement is an abnormal finding suggesting possible fetal distress or hypoxia. It indicates reduced oxygen or nutrient delivery to the fetus, often associated with maternal complications such as hypertension or preeclampsia. Immediate evaluation with fetal monitoring or ultrasound is warranted. B. Urine ketones: The absence of urine ketones is expected and does not indicate a prenatal complication. Ketones would only be concerning if elevated, as they could signal dehydration, starvation, or poorly controlled diabetes, which is not present in this case. C. Urine protein: The presence of 3+ protein in the urine is a key indicator of preeclampsia. Proteinuria results from endothelial damage in the kidneys caused by hypertension, leading to leakage of protein into the urine and confirming a serious pregnancy complication. D. Report of headache: A severe, persistent headache unrelieved by acetaminophen suggests cerebral vasospasm related to preeclampsia. It reflects increased blood pressure affecting cerebral circulation and can precede seizures or eclampsia if untreated. E. Respiratory rate: A respiratory rate of 16/min is within the normal range for adults and does not indicate a prenatal complication. There is no evidence of respiratory distress or metabolic abnormality in this finding. F. Blood pressure: A reading of 162/112 mm Hg meets the diagnostic criteria for severe hypertension in pregnancy and strongly indicates preeclampsia. Uncontrolled elevated blood pressure increases the risk of seizures, placental abruption, and fetal growth restriction. G. Gravida/parity: Being G3 P2 with one preterm birth is useful background information but not, by itself, a sign of a current complication. It helps identify obstetric history and risk factors but does not reflect an immediate prenatal concern in this assessment.

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