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?

Polyuria

Report of headache

Tachycardia

Absence of clonus

Answer and Explanation

The Correct Answer is B

Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.

Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.

Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.

Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.

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Correct Answer is C

Explanation

Choice A reason: Tampons are not safe to use to absorb the leaking amniotic fluid, because they can introduce bacteria into the vagina and uterus, and increase the risk of infection and preterm labor. The nurse should instruct the client to use sanitary pads instead, and change them frequently.

Choice B reason: Reporting a temperature less than 37 degrees C is not a necessary activity, because it is a normal finding and does not indicate any complication. The nurse should instruct the client to report a temperature greater than 37.8 degrees C, which can be a sign of infection or chorioamnionitis.

Choice C reason: Not engaging in sexual activity is a recommended activity, because it can help prevent further rupture of membranes, infection, and preterm labor. The nurse should instruct the client to avoid any vaginal or cervical stimulation, such as intercourse, douching, or tampon use.

Choice D reason: Taking frequent tub baths is not a safe activity, because it can expose the vagina and uterus to contaminated water, and increase the risk of infection and preterm labor. The nurse should instruct the client to take showers instead, and avoid submerging the lower body in water.

A. Blunt force trauma B. Hypertension C. Gestational diabetes mellitus D. Cigarette smoking

Correct Answer is B

Explanation

Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.

Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.

Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.

Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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