A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?
Blood glucose 110 mg/dL.
Urine protein of 3+.
Hemoglobin 13 g/dL.
Deep tendon reflexes of 2+.
The Correct Answer is B
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.
Choice C rationale:
A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.
Choice D rationale:
Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.
Choice B rationale:
Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.
Choice C rationale:
Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.
Choice D rationale:
Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.
Correct Answer is C
Explanation
Choice A rationale:
Preterm gestational age is not indicated by the presence of breast tissue with a flat areola and no bud. Preterm newborns may have immature breast tissue, but it does not manifest as a flat areola with no bud.
Choice B rationale:
Decreased maternal hormones during pregnancy would result in less developed breast tissue in the newborn, but it wouldn't present as a flat areola with no bud. Instead, the breast tissue may be small and less pronounced.
Choice C rationale:
Congenital anomaly refers to a birth defect or malformation that occurs during fetal development. In this case, the flat areola with no bud suggests an abnormality in the development of the breast tissue. Further assessment and evaluation may be required to determine the exact nature of the anomaly.
Choice D rationale:
Ambiguous secondary sex characteristics would involve the presence of characteristics that are not clearly male or female. The described breast tissue does not fit this category, as it is specifically described as having a flat areola with no bud, which is more indicative of a congenital anomaly.
Question 65.
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