A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Continuous fetal monitoring

Ambulate to induce labor

Obtain a daily weight

Assess deep tendon reflexes every hour

Answer and Explanation

The Correct Answer is B

Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.

Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.

Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.

Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.

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Correct Answer is B

Explanation

Choice A reason: Increased subcutaneous fat is not a typical finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have less subcutaneous fat, and may appear thin and wasted.

Choice B reason: Dry, cracked skin is a common finding in a newborn who was born at 42.5 weeks of gestation, because the skin has been exposed to the amniotic fluid for a prolonged period. The skin may also appear peeling, wrinkled, or leathery.

Choice C reason: Scant scalp hair is not a usual finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a preterm newborn. A postterm newborn tends to have more scalp hair, and may also have long nails and abundant lanugo.

Choice D reason: Copious vernix is not a specific finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have little or no vernix, which is a white, cheesy substance that protects the skin in utero.

A. Using the words lost or gone rather than dead or died. B. Setting a firm time for ending the visit with the baby so that the parents know when to let go C. Encouraging the family not to give the baby a name D. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby

Correct Answer is D

Explanation

Choice A reason: This statement is incorrect, as it is not helpful to use euphemisms or avoid the words dead or died when talking about the loss of an infant. Using the words lost or gone can imply that the baby is not really dead, or that the baby can be found or returned, which can create confusion and denial in the family. Using the words dead or died can help the family to acknowledge and accept the reality of the loss, and to express their grief and emotions.

Choice B reason: This statement is incorrect, as it is not helpful to set a firm time for ending the visit with the baby, as it can make the parents feel rushed, pressured, or controlled. Setting a firm time for ending the visit can interfere with the parents' natural process of saying goodbye to the baby, and can prevent them from creating memories and bonding with the baby. The parents should be allowed to decide how long they want to spend with the baby, and to end the visit when they are ready.

Choice C reason: This statement is incorrect, as it is not helpful to encourage the family not to give the baby a name, as it can make the baby seem less real, less important, or less valued. Encouraging the family not to give the baby a name can deny the family's right to recognize and honor the baby as a person, and to establish a relationship and an identity with the baby. The family should be supported to give the baby a name, and to use the name when referring to the baby.

Choice D reason: This statement is correct, as it is helpful to ensure the baby is clothed or wrapped if the parents choose to visit with the baby, as it can make the baby look more comfortable, warm, and human. Ensuring the baby is clothed or wrapped can facilitate the parents' physical contact and interaction with the baby, and can enhance the parents' perception and memory of the baby. The parents should be offered to choose the clothing or the blanket for the baby, and to keep them as mementos.

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A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful?

Correct Answer is D

Explanation

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has been diagnosed with hyperemesis gravidarum. Which of the following is not a risk factor for hyperemesis gravidarum?

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

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A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?