A nurse is caring for an adolescent client who is gravida 1, para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Blood pressure 148/98 mm Hg

3+ protein in the urine

1+ pitting sacral edema

Deep tendon reflexes of +1

Answer and Explanation

The Correct Answer is D

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

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Correct Answer is A

Explanation

Choice a reason:
A fundus that is palpable to the right of the midline can indicate a distended bladder. After childbirth, the bladder can become distended due to decreased sensitivity, which may be caused by trauma during delivery or the effects of anesthesia. A distended bladder can push the uterus to the side and prevent it from contracting properly, leading to increased bleeding. It's important for the nurse to encourage the client to void to relieve bladder distension and allow the uterus to contract effectively.

Choice b reason:
Less than 2.5 cm of rubra lochia on the perineal pad does not necessarily indicate bladder distension. Lochia rubra is the normal discharge of blood, mucus, and tissue from the uterus after childbirth, and its amount can vary widely among individuals. While heavy lochia can be a sign of postpartum hemorrhage, it is not directly related to bladder distension.

Choice c reason:
Increased thirst in a postpartum client is not a direct indicator of bladder distension. Thirst can be influenced by various factors, including dehydration from labor, breastfeeding, or hormonal changes. While it's important for a postpartum client to stay hydrated, increased thirst alone does not suggest a distended bladder.

Choice d reason:
Frequent uterine contractions reported by the client are not a sign of bladder distension. These contractions, known as afterpains, are normal and occur as the uterus contracts to return to its pre-pregnancy size. While uncomfortable, they are a sign of the uterus working to expel blood and tissue and do not indicate bladder issues.

A. "It detects positive antibodies in the mother's blood." B. "It detects Rh-negative antibodies in the newborn's blood." C. "It determines if kernicterus will occur in the newborn." D. "It determines the presence of maternal antibodies in the newborn's blood."

Correct Answer is A

Explanation

Choice A reason: The indirect Coombs test is used to screen for antibodies in the mother's blood that could potentially cause hemolytic disease in the newborn if they are Rh-positive. A positive result indicates that the mother has developed antibodies that could cross the placenta and attack the red blood cells of an Rh-positive fetus.

Choice B reason: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. Instead, it is used to detect antibodies in the mother's blood. The direct Coombs test is used to detect antibodies that are already attached to the red blood cells of the newborn.

Choice C reason: The indirect Coombs test does not determine if kernicterus will occur in the newborn. Kernicterus is a form of brain damage that can result from very high levels of bilirubin in a baby's blood. It is not directly related to the presence of antibodies detected by the indirect Coombs test.

Choice D reason: The indirect Coombs test does not determine the presence of maternal antibodies in the newborn's blood. This is assessed by the direct Coombs test, which checks for antibodies bound to the surface of the newborn's red blood cells, indicating that the immune system is attacking them.

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A nurse is caring for an adolescent client who is gravida 1, para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is A

Explanation

A nurse is caring for a client who is 6 hours 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 A

Explanation

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