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 ["6"]
Explanation
The Apgar s core is a s coring s ys tem doctors and nurs es us e to as s es s newborns after they’re born. The Apgar s coring s ys tem is divided into five categories : Activity, Puls e, Grimace, Appearance, and Res piration. Each category receives a s core of 0 to 2 points 1.
Bas ed on the information you provided, the newborn’s 1-min Apgar s core would be calculated as follows :
• Activity: s ome flexion of extremities = 1 point
• Puls e: heart rate 110/ min = 2 points
• Grimace: grimace in res pons e to s uctioning of the nares = 1 point
• Appearance: body pink in color with blue extremities = 1 point
• Res piration: s low, weak cry = 1 point
Adding up the points for each category, the newborn’s 1-min Apgar s core would be 6.
Correct Answer is D
Explanation
Choice A rationale:
The nurse should schedule a 3-hour oral glucose tolerance test (OGTT) for the client because the blood glucose levels taken 1 hour following a meal are higher than the expected range for gestational diabetes. This test will help to diagnose and assess the client's glucose tolerance and determine if there is gestational diabetes or any other potential glucose regulation issues.
Choice B rationale:
Increasing carbohydrates to 65% of daily nutritional intake is not the appropriate action in this situation. It may lead to further elevation of blood glucose levels, which can be detrimental for a client with gestational diabetes. The goal is to manage blood glucose levels and prevent complications, so recommending a higher carbohydrate intake would be counterproductive.
Choice C rationale:
Obtaining an HbA1c (glycated hemoglobin) is not the most suitable action in this scenario. HbA1c provides an average of the blood glucose levels over the past few months, which is more helpful for diagnosing and monitoring chronic diabetes, rather than gestational diabetes, which is temporary and occurs during pregnancy. An OGTT is a more appropriate test for gestational diabetes assessment.
Choice D rationale:
Reinforcing instruction about insulin administration is not warranted at this point since there is no information indicating that the client is currently on insulin therapy. Additionally, using insulin as the first step in the management of gestational diabetes is not common practice. Lifestyle modifications, dietary changes, and other measures are usually attempted first.
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