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

Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.

Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.

Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.

Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.

Choice A reason: AFI stands for amniotic fluid index, which is a measurement of the amount of amniotic fluid surrounding the fetus. AFI is an indicator of fetal well-being, as it reflects the fetal urine output and the placental function. A normal AFI is between 5 and 25 cm. A low AFI (< 5 cm) can suggest fetal growth restriction, oligohydramnios, or fetal distress. A high AFI (> 25 cm) can suggest fetal anomalies, polyhydramnios, or maternal diabetes.

Choice B reason: Fetal heart rate is an assessment of the fetal cardiac activity, which is usually monitored by a non-stress test (NST). Fetal heart rate is an indicator of fetal well-being, as it reflects the fetal oxygenation and the autonomic nervous system. A normal fetal heart rate is between 110 and 160 beats per minute, with moderate variability and accelerations. A non-reactive fetal heart rate (< 2 accelerations in 20 minutes) can suggest fetal hypoxia, acidosis, or distress.

Choice C reason: Fetal movement is an assessment of the fetal gross body movements, which are usually counted by the mother or observed by ultrasound. Fetal movement is an indicator of fetal well-being, as it reflects the fetal activity and the central nervous system. A normal fetal movement is at least 3 movements in 30 minutes. A decreased fetal movement (< 3 movements in 2 hours) can suggest fetal sleep, sedation, or distress.

Choice D reason: Fetal tone is an assessment of the fetal muscle tone, which is usually observed by ultrasound. Fetal tone is an indicator of fetal well-being, as it reflects the fetal maturity and the neuromuscular system. A normal fetal tone is at least 1 episode of fetal flexion or extension in 30 minutes. An abnormal fetal tone (absent or hypotonic) can suggest fetal immaturity, anomalies, or distress.

Choice E reason: Placental grade is not an assessment that is included in the fetal biophysical profile (BPP), as it is not a direct measure of fetal well-being, but rather a classification of the placental maturity and calcification. Placental grade is usually evaluated by ultrasound, and it ranges from 0 to 3, with higher grades indicating more calcification and aging. Placental grade can affect the placental function and the fetal growth, but it is not a reliable or consistent indicator of fetal distress.