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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 D

Explanation

The correct answer is choice D.

Choice A rationale:

Cervix dilation of 5 cm with 50% effacement is a sign of active phase of the first stage of labor, not the end of it.

Choice B rationale:

Rupturing of fetal membranes can occur at any time during labor, not specifically at the end of the first stage.

Choice C rationale:

Start of regular contractions is a sign of the onset of labor, not the end of the first stage.

Choice D rationale:

Cervix dilation of 10 cm with 100% effacement indicates the end of the first stage of labor and the beginning of the second stage.

A. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. B. Begins with the time of placental delivery and ends 48 hours later. C. Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments. D. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

This statement describes the second stage of labor, not the third. The second stage begins with full cervical dilation and ends with the delivery of the fetus.

Choice B rationale:

The third stage of labor does not end 48 hours after the delivery of the placenta. This choice is incorrect.

Choice C rationale:

While it’s important to ensure no placental fragments remain, the third stage of labor technically ends with the delivery of the placenta, not at this later point.

Choice D rationale:

This is the correct definition of the third stage of labor. It begins with the delivery of the fetus and ends with the delivery of the placenta.

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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?.

Nursing Test Bank

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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?.