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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 C

Explanation

The correct answer is choice C.

Choice A rationale:

Notifying the provider is not necessary in this case as the findings are normal for a client who is 1 hour postpartum.

Choice B rationale:

Increasing the frequency of fundal massage is not necessary as the fundus is firm and at the umbilicus.

Choice C rationale:

The findings are normal for a client who is 1 hour postpartum. The nurse should document the findings and continue to monitor the client. Therefore, this choice is correct.

Choice D rationale:

Encouraging the client to empty her bladder is not necessary in this case as the fundus is midline.

A. "I should keep my baby's head covered.” B. "My baby's bassinet should be kept away from fans and air conditioning.” C. "My baby's temperature will be checked rectally every hour.” D. "I should place my baby on my stomach and cover her with a warm blanket.”

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

Keeping the baby’s head covered helps to prevent heat loss, as newborns lose a significant amount of heat through their heads.

Choice B rationale:

Keeping the baby’s bassinet away from fans and air conditioning helps to maintain a stable body temperature.

Choice C rationale:

Newborns’ temperatures are typically checked every 3 to 4 hours, not every hour, and are usually done axillary, not rectally.

Choice D rationale:

Placing the baby on the mother’s stomach and covering her with a warm blanket promotes skin-to-skin contact and helps to maintain the baby’s body temperature.

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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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Correct Answer is C

Explanation

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Correct Answer is C

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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?.