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 D
Explanation
Choice A reason: Quickening is the first perception of fetal movement by the pregnant woman, usually felt between 16 and 20 weeks of gestation. However, quickening can also be confused with gas or peristalsis, which are normal digestive processes that cause sensations in the abdomen.
Choice B reason: Chadwick sign is a bluish discoloration of the cervix, vagina, and vulva due to increased blood flow during pregnancy. It can be observed by the examiner as early as 6 weeks of gestation. However, Chadwick sign can also be caused by pelvic congestion, which is a chronic condition of enlarged and dilated veins in the pelvis².
Choice C reason: Amenorrhea is the absence of menstrual periods, which is one of the most common signs of pregnancy. However, amenorrhea can also be caused by stress, endocrine problems, or other factors that affect the hormonal balance and ovulation.
Choice D reason: Goodell sign is the softening of the cervix due to increased vascularity and edema during pregnancy. It can be palpated by the examiner around 6 to 8 weeks of gestation. Goodell sign is not associated with any other condition besides pregnancy, unlike cervical polyps, which are benign growths of the cervical tissue that can cause bleeding or discharge.
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.
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