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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. At the level of the umbilicus.
Choice A rationale:
The uterine fundus is not typically found to the right of the umbilicus after delivery.
Choice B rationale:
The uterine fundus is not typically found 2 cm above the umbilicus after delivery.
Choice C rationale:
The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.
Choice D rationale:
After delivery, the uterine fundus is typically found at the level of the umbilicus.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
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