A nurse is caring for a client who is pregnant.
A nurse is evaluating the client's response to therapy. Which of the following recent assessment findings indicate the client's condition has improved or not changed?
For each recent assessment finding. click to specify if the finding indicates the client’s condition has improved or has not changed. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Deep tendon patellar reflex
Blood pressure
Edema
Heart rate
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Deep tendon patellar reflex (DTR): The client’s reflexes decreased from 4+ on Day 1 to 2+ on Day 2. Hyperactive reflexes are a hallmark of preeclampsia with severe features, so the reduction indicates an improvement in neuromuscular excitability.
Blood pressure: While slightly decreased from 166/110 mm Hg (Day 1, 0930) to 152/90 mm Hg (Day 2, 0900), indicating partial improvement with antihypertensive therapy. However, the BP remains elevated above normal range requiring further management.
Heart rate: The heart rate changed from 84–90/min (Day 1–Day 2), which is stable and within normal limits, suggesting no acute cardiovascular compromise.
Edema: The client continues to have +3 pitting edema in bilateral lower extremities on both Day 1 and Day 2, showing no change in fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Abdominal pain, often unilateral and sharp, is the classic manifestation of ectopic pregnancy due to implantation of the fertilized ovum outside the uterus (usually in the fallopian tube). If rupture occurs, pain becomes severe and may be accompanied by internal bleeding and shoulder pain.
B. Hydramnios (excess amniotic fluid) occurs in conditions like gestational diabetes, not ectopic pregnancy.
C. Bradycardia is not typical; instead, tachycardia and hypotension can occur with rupture and hemorrhage.
D. Hypertension is unrelated to ectopic pregnancy.
Correct Answer is A
Explanation
A. Advise the parent to avoid giving cow’s milk to the infant prior to 1 year of age: Cow’s milk should not be introduced before 12 months due to the risk of iron-deficiency anemia, gastrointestinal irritation, and inadequate nutrient composition.
B. Instruct the parent to give the infant water every 3 hr between feedings: Water is not routinely needed in infants under 6 months; breast milk or formula provides adequate hydration.
C. Recommend the parent mix the milk with rice cereal for feedings: Mixing cereal with cow’s milk does not make it appropriate for infants and increases the risk of nutrient imbalance.
D. Instruct the parent to give 5 mcg of vitamin D daily: Vitamin D supplementation is appropriate for breastfed infants, but this does not address the concern about cow’s milk.
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