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A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Blood pressure 160/115

Anasarca

Proteinuria 3+

Deep tendon reflexes

Answer and Explanation

The Correct Answer is D

a. This is a sign of severe preeclampsia.

b. This is a sign of severe preeclampsia.

c. This is a sign of severe preeclampsia.

d. Deep tendon reflexes are not affected by preeclampsia, which is a hypertensive disorder of pregnancy characterized by high blood pressure, proteinuria, and edema.

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Correct Answer is C

Explanation

a. This is a normal FHR pattern and is not a cause for concern.

b. These are generally benign and are not a cause for concern.

c. Late decelerations can indicate uteroplacental insufficiency and are a cause for concern.
d. This is a normal FHR and is not a cause for concern.

A. A 27-year-old G2P1 woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago but feels normal fetal movements and not contractions are noted. B. A 22-year-old. 9cm 100% +4. Who is requesting to go to the bathroom to have a bowel movement C. A 32-year-old G4P3 woman at 27 weeks' gestation who noted scan vaginal bleeding today, after of having a sexual intercourse in the morning. D. A 17-year-old. 2cm 80% -2. Who is crying and shows mild anxiety

Correct Answer is B

Explanation

a. A woman at 37 weeks' gestation who experienced spontaneous rupture of membranes 30 minutes ago with normal fetal movements is not a priority assessment as long as there are no signs of fetal distress.
b. A woman who is 9 cm dilated and fully effaced and is requesting to go to the bathroom to have a bowel movement is in the second stage of labor, which means that the cervix is fully dilated and the fetus is descending in the birth canal. The urge to have a bowel movement is a sign that the fetal head is pressing on the rectum and that delivery is imminent. This patient needs immediate attention and preparation for delivery.
c. A woman at 27 weeks' gestation who noted scant vaginal bleeding today after having sexual intercourse in the morning may be experiencing placenta previa or placental abruption but this is not a priority compared to the woman in option b who is yet to deliver.
d. A woman who is 2 cm dilated and 80% effaced and is crying and shows mild anxiety is not a priority assessment as long as there are no signs of fetal distress.

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A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which fetal heart rate (FHR) finding would concern the nurse during labor? Select one:

Correct Answer is C

Explanation

You are working in the labor and delivery unit, you received several nursing reports. Which patient should you assess first? Select one:

Correct Answer is B

Explanation

The nurse providing care for the laboring woman recognizes that late fetal heart rate (FHR) decelerations are caused by: Select one:

Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth Select one:

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A 25 years old patient at 38 weeks gestation who is in labor is being treated with magnesium sulfate for preeclampsia. Which nursing intervention does not correspond with this medication's toxicity? Select one:

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