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 D
Explanation
Choice A reason: Irregular fetal heart rate is not an expected finding in a client with a hydatidiform mole, as it can indicate fetal arrhythmia, distress, or demise. A client with a hydatidiform mole may have no fetal heart tones, as the pregnancy is nonviable and consists of abnormal trophoblastic tissue.
Choice B reason: Rapid decline in human chorionic gonadotropin (hCG) levels is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal termination of pregnancy. A client with a hydatidiform mole may have markedly elevated hCG levels, as the trophoblastic tissue secretes excessive amounts of the hormone.
Choice C reason: Profuse, clear vaginal discharge is not an expected finding in a client with a hydatidiform mole, as it can indicate a normal or abnormal cervical mucus production. A client with a hydatidiform mole may have vaginal bleeding, which is often dark brown or bright red, and may contain grape-like vesicles.
Choice D reason: Excessive uterine enlargement is an expected finding in a client with a hydatidiform mole, as it reflects the rapid growth of the trophoblastic tissue and the accumulation of fluid-filled vesicles. A client with a hydatidiform mole may have a uterus that is larger than expected for the gestational age, and may experience uterine cramping or pain.
Correct Answer is D
Explanation
Choice A reason: Placenta previa is a condition where the placenta covers the cervix partially or completely. It can cause painless vaginal bleeding, but not abdominal pain.
Choice B reason: Prolapsed cord is a condition where the umbilical cord slips through the cervix and protrudes into the vagina or beyond. It can cause fetal distress, but not abdominal pain or vaginal bleeding.
Choice C reason: Incompetent cervix is a condition where the cervix dilates prematurely and painlessly. It can cause preterm labor and delivery, but not abdominal pain or vaginal bleeding.
Choice D reason: Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery. It can cause severe abdominal pain, vaginal bleeding, and fetal distress. It is a medical emergency that requires immediate intervention.
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