A nurse is caring for an adolescent client who is gravida 1, 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 148/98 mm Hg

3+ protein in the urine

1+ pitting sacral edema

Deep tendon reflexes of +1

Answer and Explanation

The Correct Answer is D

Choice A reason:
A blood pressure reading of 148/98 mm Hg is consistent with preeclampsia. High blood pressure is a hallmark sign of preeclampsia, and a reading at or above 140/90 mm Hg is considered elevated and may warrant a preeclampsia diagnosis.

Choice B reason:
The presence of 3+ protein in the urine is another indicator consistent with preeclampsia. Proteinuria, or high levels of protein in the urine, is a common symptom of preeclampsia and can indicate kidney involvement.

Choice C reason:
1+ pitting sacral edema is also consistent with preeclampsia. While some swelling is normal during pregnancy, sudden or excessive swelling (edema) can be a sign of preeclampsia, especially when it occurs in the face, hands, or around the eyes.

Choice D reason:
Deep tendon reflexes of +1 are generally considered to be within the normal range. In preeclampsia, hyperreflexia, or increased reflexes, are more common due to heightened nervous system activity, which would be indicated by a score higher than +2². Therefore, a finding of +1 is inconsistent with preeclampsia and may suggest that reflexes are not as heightened as would typically be expected in this condition.

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Correct Answer is B

Explanation

Choice A reason:
While burping can be a sign that a baby is feeding, it is not a reliable indicator of whether the baby is getting enough breast milk. Burping is a way to release air that babies swallow during feeding, which can help prevent discomfort and gas. However, it does not correlate directly with the amount of milk intake.

Choice B reason:
The number of wet diapers is a direct indicator of a baby's hydration status and, by extension, how much breast milk they are receiving. A newborn who is getting enough milk will typically have 6 to 8 wet diapers per day after the first few days of life. This shows that the baby is well-hydrated and is receiving sufficient milk.

Choice C reason:
Sleep patterns in newborns can vary widely, and sleeping for at least 6 hours between feedings is not typical for a 2-day-old baby. Newborns usually need to feed every 2 to 3 hours, and long stretches of sleep without feeding may indicate that the baby is not getting enough milk and does not have the energy to wake and feed.

Choice D reason:
A wake cycle of 30 to 60 minutes after feeding can be normal for some babies, but it is not a measure of whether they are getting enough milk. The wake cycle can be influenced by many factors, including the baby's overall health, comfort, and environment.

A. Increased subcutaneous fat B. Scant scalp hair C. Dry, cracked skin D. Copious vernix

Correct Answer is C

Explanation

The correct answer is choice C. Dry, cracked skin.

Choice A rationale:

Increased subcutaneous fat is more commonly seen in full-term infants, but post-term infants (born after 42 weeks) often have decreased subcutaneous fat due to the aging placenta’s reduced efficiency in nutrient delivery.

Choice B rationale:

Scant scalp hair is typically seen in preterm infants. Post-term infants usually have more developed features, including more scalp hair.

Choice C rationale:

Dry, cracked skin is a common finding in post-term infants because the protective vernix caseosa, which covers the skin in utero, has often been shed by this stage. The prolonged exposure to amniotic fluid can lead to skin that appears dry, cracked, and peeling.

Choice D rationale:

Copious vernix is usually seen in preterm infants. By 42.5 weeks, most of the vernix has been absorbed or shed, leading to the dry skin observed in post-term infants.

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A nurse is caring for an adolescent client who is gravida 1, 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

"How will I know if my baby is getting enough breast milk?"

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

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