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 B

Explanation

Choice A reason: Reinforcing postpartum and newborn care discharge teaching is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Reinforcing postpartum and newborn care discharge teaching is an important intervention that can help the client to manage her physical recovery and her infant's needs, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.

Choice B reason: Asking the client if she has considered harming her newborn is a priority action by the nurse, as it is essential to assess the client's risk of infanticide, which is the intentional killing of an infant by the mother. Asking the client if she has considered harming her newborn is a sensitive and difficult question, but it is necessary to ensure the safety of the infant and the mother, and to provide appropriate interventions and referrals. The nurse should ask the question in a nonjudgmental and supportive manner, and validate the client's feelings and concerns.

Choice C reason: Assisting the family to identify prior use of positive coping skills in family crises is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Assisting the family to identify prior use of positive coping skills in family crises is a helpful intervention that can enhance the client's resilience and self-efficacy, but it is not sufficient to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being.

Choice D reason: Anticipating a prescription by the provider for an antidepressant is not a priority action by the nurse, as it is not directly related to the client's emotional state or safety. Anticipating a prescription by the provider for an antidepressant is a possible intervention that can improve the client's mood and functioning, but it is not the only or the first option to address the client's symptoms of postpartum depression, which is a mood disorder that can affect the client's mental health and well-being. The nurse should collaborate with the provider and the client to determine the best treatment plan, which may include psychotherapy, social support, or alternative therapies.

A. "It promotes fetal lung maturity." B. "It halts cervical dilation." C. "It increases the fetal heart rate." D. "It is used to stop preterm labor contractions."

Correct Answer is A

Explanation

Choice A reason: This statement is correct, as betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering before 34 weeks of gestation. Betamethasone stimulates the production of surfactant, which is a substance that prevents the alveoli from collapsing and improves the lung function of the fetus.

Choice B reason: This statement is incorrect, as betamethasone does not affect the cervical dilation, which is a sign of labor progression. Betamethasone does not stop or delay labor, but rather reduces the complications of prematurity, such as respiratory distress syndrome, intraventricular hemorrhage, or necrotizing enterocolitis.

Choice C reason: This statement is incorrect, as betamethasone does not increase the fetal heart rate, which is a measure of fetal well-being. Betamethasone may cause transient fetal bradycardia, which is a decrease in the fetal heart rate, due to the increased vagal tone and blood pressure. The nurse should monitor the fetal heart rate and notify the provider if there are any signs of fetal distress.

Choice D reason: This statement is incorrect, as betamethasone is not used to stop preterm labor contractions, which are caused by the uterine muscle activity. Betamethasone does not have any tocolytic effect, which is the ability to inhibit uterine contractions. Other medications, such as magnesium sulfate, nifedipine, or indomethacin, may be used to stop preterm labor contractions.

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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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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling very sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new order for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

Correct Answer is A

Explanation

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