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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering oxygen via nasal cannula is not a necessary intervention for the client, unless she has signs of hypoxia, such as dyspnea, tachypnea, or cyanosis. Oxygen administration is not routinely indicated for clients with inevitable abortion.
Choice B reason: Offering option to view products of conception is an appropriate intervention for the client, because it can help her cope with the loss of pregnancy and facilitate the grieving process. The nurse should respect the client's decision and provide emotional support.
Choice C reason: Instructing the client to increase potassium-rich foods in the diet is not a relevant intervention for the client, unless she has signs of hypokalemia, such as muscle weakness, cramps, or arrhythmias. Potassium intake is not related to the cause or prevention of inevitable abortion.
Choice D reason: Maintaining the client in a Trendelenburg position is not a recommended intervention for the client, because it can increase the risk of aspiration, respiratory compromise, and venous congestion. Trendelenburg position is not effective in preventing or treating inevitable abortion.
Correct Answer is D
Explanation
Choice A reason: Using fingertips when calming the newborn is not recommended, as it can overstimulate the immature nervous system and cause stress. Instead, the nurse should use gentle, firm, and sustained touch, such as cupping the head and feet, or swaddling the newborn.
Choice B reason: Positioning the premature infant on their abdomen is contraindicated, as it can increase the risk of sudden infant death syndrome (SIDS). The nurse should position the newborn on their back or side, with a rolled blanket or towel to support the spine and prevent flattening of the head.
Choice C reason: Keeping the newborn in a well-lit nursery is not advisable, as it can interfere with the development of the circadian rhythm and sleep patterns. The nurse should provide a dark and quiet environment for the newborn, and expose them to natural light during the day.
Choice D reason: Clustering the newborn's care activities is beneficial, as it can reduce the number of disruptions and allow for longer periods of rest and growth. The nurse should plan and coordinate the care activities, such as feeding, bathing, changing, and assessing, to minimize the stress on the newborn.
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