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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. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only. B. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. C. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. D. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.

Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

While it’s true that breastfed infants may lose 5% to 10% of their birth weight in the first few days, this is not exclusive to breastfed infants.

Choice B rationale:

Formula-fed babies may gain weight more quickly than breastfed babies, but they do not typically show an increase in weight by day 3.

Choice C rationale:

Both formula-fed and breastfed newborns can lose 5% to 10% of their birth weight in the first few days.

Choice D rationale:

While formula-fed newborns may gain weight more quickly than breastfed newborns, they do not typically gain 3% to 5% of the initial birth weight in the first 48 hours.

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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?.