A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Elevated blood pressure

Increased urine output

Joint pain

Vaginal discharge

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevated blood pressure is a hallmark sign of preeclampsia, which is a hypertensive disorder of pregnancy that can cause serious complications, such as eclampsia, HELLP syndrome, or placental abruption. The nurse should monitor the client's blood pressure regularly and report any readings above 140/90 mm Hg to the provider.

Choice B reason: Increased urine output is not a sign of preeclampsia, but rather a normal physiological change of pregnancy, as the renal blood flow and glomerular filtration rate increase. A client with preeclampsia may have decreased urine output, which can indicate renal impairment or oligohydramnios.

Choice C reason: Joint pain is not a sign of preeclampsia, but rather a common discomfort of pregnancy, as the hormones relaxin and progesterone loosen the ligaments and joints. A client with preeclampsia may have epigastric pain, which can indicate liver involvement or impending eclampsia.

Choice D reason: Vaginal discharge is not a sign of preeclampsia, but rather a normal occurrence of pregnancy, as the cervical glands secrete more mucus to protect the uterus from infection. A client with preeclampsia may have vaginal bleeding, which can indicate placental abruption or disseminated intravascular coagulation.

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Correct Answer is C

Explanation

Choice A reason: This statement is incorrect, as it describes the direct Coombs test, not the indirect Coombs test. The direct Coombs test is performed on the newborn's blood, and it detects the presence of maternal antibodies that have attached to the newborn's red blood cells. The direct Coombs test can help diagnose hemolytic disease of the newborn, which is a condition where the maternal antibodies destroy the newborn's red blood cells, causing anemia and jaundice.

Choice B reason: This statement is incorrect, as it is not the purpose of the indirect Coombs test, but rather a possible complication of hemolytic disease of the newborn. Kernicterus is a severe form of jaundice that occurs when the bilirubin level in the blood is very high, and it can cause brain damage, deafness, or death. Kernicterus can be prevented by treating the jaundice with phototherapy or exchange transfusion.

Choice C reason: This statement is correct, as it describes the indirect Coombs test, which is performed on the mother's blood, and it detects the presence of Rh-positive antibodies that have formed in response to the exposure to the Rh-positive blood of the newborn. The indirect Coombs test can help identify the risk of hemolytic disease of the newborn, and guide the administration of Rh immunoglobulin, which is a medication that prevents the formation of Rh-positive antibodies.

Choice D reason: This statement is incorrect, as it is not possible for the newborn to have Rh-negative antibodies, since the newborn has Rh-positive blood. Rh-negative antibodies are produced by Rh-negative individuals who have been exposed to Rh-positive blood, such as Rh-negative mothers who have Rh-positive newborns. Rh-negative antibodies can cross the placenta and attack the Rh-positive red blood cells of the newborn, causing hemolytic disease of the newborn.

A. Increased risk of anemia B. Hyperinsulinemia C. Increased blood viscosity D. Brachial plexus injury

Correct Answer is B

Explanation

Choice A reason: Increased risk of anemia is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn regardless of the maternal diabetes status or the fetal size. Anemia can cause pallor, tachycardia, and poor feeding, but not respiratory distress.

Choice B reason: Hyperinsulinemia is a likely cause of respiratory distress in a term macrosomic newborn, as it results from the fetal exposure to high maternal glucose levels and the subsequent overproduction of insulin. Hyperinsulinemia can impair the synthesis of surfactant, which is a substance that prevents the alveoli from collapsing and facilitates gas exchange. Hyperinsulinemia can also cause hypoglycemia, which can affect the respiratory center and cause apnea.

Choice C reason: Increased blood viscosity is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn with polycythemia, which is an abnormally high number of red blood cells. Polycythemia can cause cyanosis, jaundice, and thrombosis, but not respiratory distress.

Choice D reason: Brachial plexus injury is not a likely cause of respiratory distress in a term macrosomic newborn, as it affects the nerves that supply the arm and hand, not the lungs. Brachial plexus injury can occur due to the excessive traction or stretching of the shoulder during delivery, and can cause weakness, paralysis, or sensory loss in the affected arm.

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A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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