A nurse is admitting a patient who is at 38 weeks gestation and has severe pre-eclampsia. When assessing the patient, the nurse should expect which finding?

Polyuria

Tachycardia

Headache

Diplopia

Answer and Explanation

The Correct Answer is C

A. Pre-eclampsia is usually associated with oliguria (reduced urine output) due to renal vasoconstriction and decreased glomerular filtration. Polyuria is not expected and may indicate another condition, such as diabetes mellitus.

B. While mild increases in heart rate can occur, tachycardia is not a hallmark sign of pre-eclampsia. Blood pressure elevation, rather than heart rate changes, is the primary cardiovascular finding.

C. Severe pre-eclampsia is characterized by hypertension with systemic involvement, and persistent, severe headaches are common due to cerebral edema and vasospasm. Headaches are a classic symptom and often a warning sign for potential complications such as eclampsia.

D. Visual disturbances can occur in pre-eclampsia (e.g., blurred vision, scotomata, or spots), but diplopia (double vision) is less common. Headache is a more consistent and expected finding in severe pre-eclampsia.

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Correct Answer is D

Explanation

A. Developmental milestones follow predictable sequences, but the exact age at which each child reaches them can vary. Expecting all babies to reach milestones at the same age is unrealistic and does not reflect normal variation in growth and development.

B. While gross motor skills like walking often develop alongside fine motor skills, fine motor development does not occur automatically. It requires practice, coordination, and maturation of muscles and nervous system pathways.

C. Genetics play a significant role in growth, influencing height, weight, body proportions, and sometimes developmental timing. Denying the influence of genetics misrepresents a key factor in growth and development.

D. This statement reflects an accurate understanding of developmental principles. Growth and developmental milestones occur in a predictable sequence (cephalocaudal, proximodistal, and simple-to-complex patterns), but the timing can vary for each child. This acknowledges normal individual differences while recognizing typical developmental patterns.

A. Advise the client that occasional drug use is safe during pregnancy B. offer nonjudgmental counseling and referrals to support services C. Encourage abrupt discontinuation of all opioids D. Monitor the newborn for signs of neonatal abstinence syndrome (NAS) E. Provide methadone therapy as prescribed

Correct Answer is ["B","D","E"]

Explanation

A. This is incorrect. There is no safe level of illicit opioid use during pregnancy. Encouraging or implying safety could put both the mother and fetus at serious risk, including preterm labor, low birth weight, and neonatal abstinence syndrome (NAS).

B. Providing a supportive, nonjudgmental approach encourages the client to engage in care, disclose substance use, and access rehabilitation, counseling, and social services, which improves maternal and fetal outcomes.

C. Abrupt cessation of opioids in a dependent pregnant client can lead to maternal withdrawal, fetal distress, preterm labor, or miscarriage. Safe management involves medically supervised opioid replacement therapy, not sudden discontinuation.

D. Infants exposed to opioids in utero are at risk for NAS, which includes tremors, irritability, feeding difficulties, respiratory problems, and seizures. Early identification and intervention are essential.

E. Methadone or buprenorphine therapy is the standard of care for managing opioid dependence during pregnancy. These therapies stabilize maternal opioid levels, reduce illicit drug use, and improve pregnancy outcomes. Therapy should be medically supervised.

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A nurse is admitting a patient who is at 38 weeks gestation and has severe pre-eclampsia. When assessing the patient, the nurse should expect which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a parent about normal infant growth and development. Which statement by the parent indicates they can apply developmental principles correctly to their own child?

Correct Answer is D

Explanation

A pregnant client has a history of opioid dependence. Which of the following are appropriate nursing interventions for managing her care? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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