The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply)
Seizure activity and hypotension
Platelet count of less than 100,000/mm3 and visual problems
Ankle clonus and epigastric pain
Decreased urinary output and irritability
Correct Answer : B,C,D
Choice A reason: Seizure activity and hypotension are not signs and symptoms of severe preeclampsia, but rather of eclampsia, which is a life-threatening complication of preeclampsia. Eclampsia is characterized by convulsions and coma, and it requires immediate treatment to prevent maternal and fetal death.
Choice B reason: Platelet count of less than 100,000/mm3 and visual problems are signs and symptoms of severe preeclampsia, as they indicate hematologic and neurologic complications. Severe preeclampsia can cause thrombocytopenia, which is a low platelet count that increases the risk of bleeding. It can also cause cerebral edema, which can impair the vision and cause blurred vision, spots, or flashes of light.
Choice C reason: Ankle clonus and epigastric pain are signs and symptoms of severe preeclampsia, as they indicate neuromuscular and hepatic complications. Severe preeclampsia can cause hyperreflexia, which is an exaggerated reflex response that can be elicited by dorsiflexing the ankle and observing rhythmic jerking of the foot. It can also cause liver damage, which can manifest as epigastric pain or right upper quadrant pain.
Choice D reason: Decreased urinary output and irritability are signs and symptoms of severe preeclampsia, as they indicate renal and central nervous system complications. Severe preeclampsia can cause oliguria, which is a reduced urine output of less than 500 mL in 24 hours. It can also cause increased intracranial pressure, which can affect the mood and behavior and cause irritability, anxiety, or confusion.
Choice E reason: Transient headache and +1 proteinuria are not signs and symptoms of severe preeclampsia, but rather of mild preeclampsia, which is a less severe form of the condition. Mild preeclampsia is characterized by blood pressure of 140/90 mm Hg or higher, proteinuria of 1+ or higher, and mild edema. It does not cause severe complications or organ damage, but it can progress to severe preeclampsia if not treated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Infection is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Marginal placenta previa is a type of placenta previa where the edge of the placenta is near the cervical os but does not cover it. It can cause painless bleeding during pregnancy or labor, but it does not increase the risk of infection.
Choice B reason: Hemorrhage is the greatest risk for a woman with marginal placenta previa, as it can occur due to the separation of the placenta from the uterine wall during labor or delivery. The bleeding can be profuse and life-threatening, and it requires prompt intervention and monitoring.
Choice C reason: Urinary retention is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Urinary retention is the inability to empty the bladder completely, and it can occur due to various factors such as anesthesia, trauma, or medication. It can cause discomfort, infection, or bladder distension, but it is not as serious as hemorrhage.
Choice D reason: Thrombophlebitis is not the greatest risk for a woman with marginal placenta previa, as it is not directly related to the condition. Thrombophlebitis is the inflammation of a vein due to a blood clot, and it can occur due to prolonged bed rest, dehydration, or injury. It can cause pain, swelling, or redness in the affected area, and it can lead to pulmonary embolism if the clot dislodges and travels to the lungs. However, it is not as common or as severe as hemorrhage.
Correct Answer is A
Explanation
Choice A reason: This is the best advice for the woman, as it acknowledges that jogging is safe and beneficial in early pregnancy, but also informs her that she may need to adjust her exercise intensity and duration as her pregnancy progresses. Walking is a low-impact aerobic activity that can be done throughout pregnancy, as long as there are no complications or contraindications. Walking can help maintain cardiovascular fitness, prevent excessive weight gain, and reduce the risk of gestational diabetes and preeclampsia.
Choice B reason: This is not a good advice for the woman, as it implies that jogging is harmful for her joints and that she should stop it immediately. Jogging is not necessarily bad for the joints, as long as the woman wears appropriate shoes, avoids uneven surfaces, and listens to her body. Jogging can also provide many health benefits for the woman and the fetus, such as improved mood, increased energy, and reduced stress².
Choice C reason: This is a false and alarming statement that may discourage the woman from exercising at all. Exercise during pregnancy is not dangerous for the fetus unless there are specific medical conditions or complications that prevent it. Exercise during pregnancy can improve the fetal growth, development, and oxygenation, as well as reduce the risk of preterm birth and low birth weight.
Choice D reason: This is an unrealistic and misleading statement that may cause the woman to overexert herself or ignore the signs of discomfort or fatigue. Exercise during pregnancy may need to be modified according to the woman's changing needs, abilities, and preferences. Some factors that may affect the type, frequency, intensity, and duration of exercise during pregnancy include the trimester, the fetal position, the maternal weight, the environmental temperature, and the presence of any symptoms or complications.
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