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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","F"]
Explanation
The correct answers are choices B, E, and F.
Choice A rationale:
Nausea with vomiting during the first trimester is a common symptom of pregnancy and does not need to be reported immediately to the health care provider.
Choice B rationale:
Sudden leakage of fluid during the second trimester could indicate premature rupture of membranes, which can lead to infection and preterm labor. This should be reported immediately.
Choice C rationale:
Urinary frequency in the third trimester is a common symptom of pregnancy due to the growing uterus putting pressure on the bladder.
Choice D rationale:
Backache during the second trimester is a common symptom of pregnancy as the body adjusts to the growing uterus.
Choice E rationale:
Lower abdominal pain with shoulder pain in the first trimester could indicate an ectopic pregnancy, which is a medical emergency and should be reported immediately.
Choice F rationale:
Headache with visual changes in the third trimester could indicate preeclampsia, a serious condition that can lead to seizures, stroke, and other complications. This should be reported immediately.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
The GTPAL system stands for Gravida, Term, Preterm, Abortions, and Living children. In this case, the woman has been pregnant 4 times (Gravida 4), has had one term birth (Term 1), one preterm birth (Preterm 1), one abortion/miscarriage (Abortions 1), and one living child (Living 1). Therefore, the correct classification is 4, 1, 1, 1, 1.
Choice B rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and does not account for the preterm birth or the number of living children.
Choice C rationale:
This choice overcounts the number of term births and living children.
Choice D rationale:
This choice incorrectly classifies the number of pregnancies (Gravida should be 4, not 3) and overcounts the number of living children.
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