A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?
Decreased BUN
Increased protein in urine
Increased platelet count
Decreased serum uric acid
The Correct Answer is B
Choice A reason: Decreased BUN is not typical in preeclampsia, where renal impairment often elevates BUN due to reduced glomerular filtration. Normal or increased BUN is expected, so this finding does not align with preeclampsia’s pathophysiology, making it an incorrect expectation.
Choice B reason: Increased protein in urine (proteinuria) is a hallmark of preeclampsia, resulting from glomerular damage due to hypertension and endothelial dysfunction. This diagnostic criterion, often >300 mg/24 hours, is critical for identifying preeclampsia, making it the correct finding the nurse should expect.
Choice C reason: Increased platelet count is not associated with preeclampsia, which often causes thrombocytopenia due to endothelial activation and platelet consumption. A decreased count (<100,000/mm³) is more likely, making this finding incorrect for preeclampsia’s clinical presentation.
Choice D reason: Decreased serum uric acid is not expected in preeclampsia, where elevated uric acid occurs due to reduced renal clearance from glomerular dysfunction. Increased levels are a marker, so this finding is opposite to preeclampsia’s effects, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Frequent swallowing is a key indicator of post-tonsillectomy hemorrhage, as the child may swallow blood from bleeding in the surgical site. This subtle sign requires urgent assessment to prevent airway obstruction or significant blood loss, aligning with clinical priorities, making it the correct finding.
Choice B reason: Increased drowsiness may indicate pain medication effects or general recovery but is not specific to hemorrhage. While concerning, it is less urgent than frequent swallowing, which directly suggests bleeding, making this finding less indicative of hemorrhage in this context.
Choice C reason: Elevated pain is expected post-tonsillectomy due to surgical trauma and does not specifically indicate hemorrhage. Pain may persist regardless of bleeding, so this finding is less reliable than frequent swallowing for identifying potential hemorrhage, making it incorrect.
Choice D reason: Diminished breath sounds suggest respiratory complications like atelectasis or obstruction, not hemorrhage. Bleeding would more likely present with swallowing or visible blood. This finding is unrelated to tonsillectomy hemorrhage, making it an incorrect indicator for this complication.
Correct Answer is D
Explanation
Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.
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