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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A routine abdominal ultrasound is not used to assess bone age or growth delays. While abdominal ultrasounds can detect organ abnormalities, they provide no information about skeletal maturation.
B. A complete blood count (CBC) evaluates blood cell levels and can detect anemia or infection, but it does not provide information about bone growth or skeletal development.
C. A hand-wrist X-ray is the standard diagnostic test to assess bone age and skeletal maturation. By comparing the X-ray of the child’s hand and wrist bones to standardized age-related charts (such as the Greulich and Pyle atlas), providers can determine if the child’s skeletal growth is appropriate for chronological age. This helps identify growth delays, endocrine disorders, or other conditions affecting stature.
D. Anthropometric hand-wrist measurement refers to physical measurements of the hand and wrist, which do not provide sufficient information to determine bone age or detect growth delays. X-ray imaging is required for accurate assessment of skeletal maturity.
Correct Answer is A
Explanation
A. Infant motor development follows a proximal-to-distal pattern, meaning control develops from the center of the body outward. At 7 months, infants first gain control of shoulders and arms, allowing them to reach with the whole hand. Later, fine motor skills like the pincer grasp (using thumb and forefinger) develop around 9–12 months, enabling the child to pick up small objects. This progression is typical and expected.
B. At 7 months, infants are still developing bilateral coordination. It is normal for a baby to favor one hand or alternate hands inconsistently. Expecting equal use of both hands at this stage reflects a misunderstanding of normal motor development.
C. Fine motor skills, such as using the thumb and forefinger to grasp small objects, emerge later. Reaching with the whole hand at 7 months is part of normal development. Labeling it as delayed is incorrect and may cause unnecessary concern.
D. The infant is following the typical developmental sequence, progressing from gross motor to fine motor control. Reaching with one hand before using the pincer grasp does not indicate skipped milestones. Developmental milestones are achieved in a predictable order, and this behavior is within normal limits.
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