A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?
Hypotension.
Headache.
Tachycardia.
Polyuria.
The Correct Answer is B
Choice A rationale:
Hypotension is not an expected finding in a client with severe preeclampsia. In preeclampsia, the client typically experiences hypertension (high blood pressure) rather than hypotension (low blood pressure). Hypotension may be concerning as it could indicate inadequate perfusion to vital organs.
Choice B rationale:
Headache is an expected finding in a client with severe preeclampsia. Headaches are a common symptom of preeclampsia and are often described as persistent and severe. They can result from increased blood pressure and possibly cerebral oedema.
Choice C rationale:
Tachycardia is not an expected finding in a client with severe preeclampsia. Tachycardia refers to an abnormally fast heart rate, but in preeclampsia, bradycardia (abnormally slow heart rate) or a normal heart rate is more typical. Tachycardia could indicate other underlying issues.
Choice D rationale:
Polyuria is not an expected finding in a client with severe preeclampsia. Polyuria is characterized by excessive urination, and in preeclampsia, the opposite may occur due to decreased kidney perfusion, resulting in oliguria (reduced urine output).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Supporting the infant during birth. The priority for the nurse in this situation is to ensure the safe delivery of the baby. By supporting the infant during birth, the nurse can help ensure that the baby is delivered safely and efficiently. This involves assisting the mother in pushing and guiding the baby's head and body as it emerges from the birth canal. The nurse should also be ready to catch the baby and provide immediate care, such as drying and stimulating the baby to breathe if necessary.
Choice B rationale
Preventing the perineum from tearing. While preventing perineal tearing is important, it is not the top priority in this rapidly progressing labor scenario. The immediate concern is the safe delivery of the baby, and if perineal tearing does occur, it can be addressed after the birth.
Choice C rationale
Cutting the umbilical cord. This action is necessary but not the top priority. After the baby is delivered, the nurse should clamp and cut the umbilical cord to separate the baby from the placenta. However, this can wait until the baby is fully delivered and breathing on their own.
Choice D rationale
Promoting delivery of the placenta. Again, while delivering the placenta is important to prevent postpartum haemorrhage, it is not the priority in this scenario. The nurse's immediate focus should be on supporting the infant's delivery and ensuring the baby's well-being.
Correct Answer is B
Explanation
The correct answer is choice B: “You must be feeling very scared.” This response is an example of therapeutic communication, where the nurse acknowledges the client’s feelings and provides emotional support without making assumptions or giving false reassurances.
Choice A rationale: While it’s true that the presence of a neonatal unit equipped to handle emergencies is reassuring, this response does not address the client’s immediate emotional needs or fears. It’s important for the nurse to recognize and validate the client’s feelings rather than focusing solely on the facilities available.
Choice B rationale: This choice demonstrates empathy and understanding. It allows the client to express their feelings and concerns, which is a crucial aspect of providing emotional support during labor. By acknowledging the client’s potential fear, the nurse opens the door for further communication and support.
Choice C rationale: This response minimizes the client’s individual feelings by suggesting that everyone has the same worries. It can make the client feel that their concerns are not unique or taken seriously, which is not conducive to establishing trust or providing individualized care.
Choice D rationale: This choice provides false reassurance. At 32 weeks of gestation, while the prognosis for the baby is generally good, there are still risks associated with preterm birth. It’s important not to make definitive statements about outcomes that cannot be guaranteed.
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