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A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia.
Which of the following is an expected finding?.

Report of headache.

Absence of clonus.

Polyuria.

Tachycardia.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

A headache is a common symptom of severe preeclampsia due to increased blood pressure in the brain.

Choice B rationale:

The presence, not absence, of clonus (a series of involuntary muscular contractions and relaxations) is a sign of severe preeclampsia.

Choice C rationale:

Oliguria, not polyuria, is a symptom of severe preeclampsia due to decreased renal perfusion.

Choice D rationale:

Tachycardia is not typically associated with preeclampsia. It could be a sign of other complications.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Fetal heart tones detected by ultrasound are a positive sign of pregnancy because they provide direct evidence of a fetus.

Choice B rationale:

Breast tenderness is a presumptive sign of pregnancy, not a positive one, as it can be caused by other conditions such as premenstrual syndrome.

Choice C rationale:

A positive urine pregnancy test is a probable sign of pregnancy, not a positive one, as it measures the presence of hCG, a hormone produced during pregnancy. However, certain medications and medical conditions can also produce hCG.

Choice D rationale:

Fatigue is a presumptive sign of pregnancy, not a positive one, as it can be caused by various other conditions such as stress or illness.

A. She did her perineal care independently. B. She is eager to talk about her birth experience. C. She has not asked for anything for pain all day. D. She sits and rocks her infant for long intervals.

Correct Answer is A

Explanation

The correct answer is choice A. She did her perineal care independently.

Choice A rationale:

Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.

Choice B rationale:

Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.

Choice C rationale:

Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.

Choice D rationale:

Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.

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A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia.Which of the following is an expected finding?.

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A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia.
Which of the following is an expected finding?.