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 D

Explanation

Choice a reason:
Monitoring the heart rate is important for any newborn, but it is not the priority intervention for an SGA newborn. SGA newborns are at risk for several complications, but abnormal heart rates are not a primary concern directly related to being small for gestational age.

Choice b reason:
While monitoring weight is a part of routine newborn care and important for tracking growth and development, it is not the most immediate concern for an SGA newborn. The priority is to address potential acute complications that can arise from being small for gestational age.

Choice c reason:
Monitoring axillary temperature is important for maintaining normothermia in newborns, especially those who are SGA, as they have less subcutaneous fat and are more prone to heat loss. However, the most critical and immediate risk for SGA newborns is hypoglycemia, making blood glucose monitoring a higher priority.

Choice d reason:
SGA newborns are at increased risk for hypoglycemia due to their decreased glycogen stores. Therefore, monitoring blood glucose levels is a priority intervention. Hypoglycemia can lead to serious complications such as seizures and brain injury if not promptly identified and treated. It is essential to monitor blood glucose levels frequently and intervene as necessary to maintain them within a normal range.

A. "Once you show me your photo identification, you can take the infant." B. "Have the mother call and I will take the baby to the room." C. "You can push the baby to the room in a wheeled bassinet." D. "You may carry your grandchild to the room."

Correct Answer is B

Explanation

Choice A reason: Requesting photo identification from the grandmother is a standard security procedure in many hospitals to ensure the safety of the newborn. However, this option alone does not address the hospital's policy regarding who is permitted to transport infants. Typically, only hospital staff are allowed to move infants within the facility to ensure their safety and security.

Choice B reason: This choice aligns with common hospital policies that require a staff member, such as a nurse, to transport newborns. It ensures that the baby remains under the care of trained personnel during transport and helps prevent potential mix-ups or security issues. The nurse's offer to take the baby to the room upon the mother's request also supports family involvement in the care process while maintaining safety protocols.

Choice C reason: Allowing the grandmother to push the baby to the room in a wheeled bassinet may seem convenient, but it is not typically permitted due to safety and security protocols. Hospitals often have strict regulations about who can transport babies to prevent abductions and ensure that the infant is always accompanied by a staff member.

Choice D reason: While it may be a heartwarming gesture for the grandmother to carry her grandchild, it is not an appropriate response by the nurse. Newborns should be transported in a secure manner, which usually means being in a bassinet or held by hospital staff. Personal carrying increases the risk of falls or other accidents.

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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 planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Correct Answer is D

Explanation

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

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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?

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD format. For example, July 27 is 0727.)

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

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