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:
Suctioning excess mucus with a bulb syringe is a standard procedure to clear the airways of a newborn and facilitate breathing. While it is an important aspect of initial newborn care, it does not directly prevent jaundice. Jaundice is caused by high levels of bilirubin in the blood, and suctioning mucus does not influence bilirubin levels.

Choice B reason:
Initiating early feeding, whether breastfeeding or formula feeding, is recommended to prevent jaundice. Early feeding helps stimulate bowel movements, which aids in the excretion of bilirubin through the stool. Breastfed babies should be fed eight to twelve times a day during their first week of life, and formula-fed babies should receive one to two ounces (30 to 60 milliliters) of formula every two to three hours during their first week. This frequent feeding schedule helps ensure that bilirubin does not build up to high levels in the newborn's system.

Choice C reason:
Preparing for an exchange blood transfusion is a treatment measure for severe jaundice, not a preventive action. This procedure is only considered when bilirubin levels are dangerously high and could potentially cause brain damage. It is not a standard preventive measure for jaundice in newborns.

Choice D reason:
Beginning phototherapy is a treatment method for newborns who have already developed jaundice, not a preventive measure. Phototherapy uses light to break down bilirubin in the skin, making it easier for the baby's body to eliminate it. While effective in treating jaundice, it is not used as a preventive action.
Question 65

A. Hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days B. Hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth C. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months D. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen

Correct Answer is B

Explanation

Choice A reason:
This choice is incorrect because the hepatitis B vaccine is recommended to be given within 24 hours of birth, but there is no recommendation for hepatitis B immune globulin (HBIG) to be given every 12 hours for 3 days. The HBIG is typically given as a single dose.

Choice B reason:
This is the correct choice. Newborns whose mothers are positive for the hepatitis B surface antigen should receive both HBIG and the first dose of the hepatitis B vaccine within 12 hours of birth. The HBIG provides immediate protection against hepatitis B infection, and the vaccine begins the process of building long-term immunity.

Choice C reason:
This choice is incorrect because delaying the administration of HBIG and the hepatitis B vaccine until 1 week after birth would leave the newborn vulnerable to hepatitis B infection. The recommended schedule is to administer these within 12 hours of birth.

Choice D reason:
This choice is incorrect because the hepatitis B vaccine is not given monthly. The typical schedule for the hepatitis B vaccine is the first dose at birth, the second dose at 1-2 months of age, and the third dose at 6 months of age. Additionally, the vaccine is not administered based on the newborn's hepatitis B surface antigen status.

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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

A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Correct Answer is B

Explanation

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive?

Correct Answer is B

Explanation

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