A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?
Polyuria
Report of headache
Tachycardia
Absence of clonus
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Providing a dark, quiet environment is an appropriate action for the nurse to implement, because it can help reduce the client's blood pressure and prevent seizures.
Choice B reason: Evaluating neurologic status every 12 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should assess the client's neurologic status every 2 to 4 hr, or more often if indicated, to detect signs of cerebral edema or eclampsia.
Choice C reason: Assessing respiratory status every 8 hr is not an appropriate action for the nurse to implement, because it is not frequent enough. The nurse should monitor the client's respiratory status every 1 to 2 hr, or more often if indicated, to detect signs of pulmonary edema or respiratory depression.
Choice D reason: Ensuring that calcium gluconate is readily available is an appropriate action for the nurse to implement, because it is the antidote for magnesium sulfate toxicity. The nurse should have calcium gluconate on hand and know how to administer it in case of an emergency.
Choice E reason: Administering magnesium sulfate IV is an appropriate action for the nurse to implement, because it is the drug of choice for preventing and treating seizures in clients with severe gestational hypertension. The nurse should follow the protocol for magnesium sulfate administration and monitor the client's vital signs, urine output, reflexes, and serum magnesium levels.
Correct Answer is D
Explanation
Choice A reason: Thrombophlebitis is a condition where a blood clot forms in a vein and causes inflammation and pain. The risk factors for thrombophlebitis include immobility, dehydration, obesity, smoking, and cesarean birth. This client is not at increased risk for thrombophlebitis based on the information given.
Choice B reason: Retained placental fragments are pieces of the placenta that remain in the uterus after delivery and can cause bleeding, infection, or uterine subinvolution. The risk factors for retained placental fragments include placenta previa, placenta accreta, manual removal of the placenta, and incomplete separation of the placenta. This client is not at increased risk for retained placental fragments based on the information given.
Choice C reason: Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery and can cause fever, malaise, abdominal pain, and foul-smelling lochia. The risk factors for puerperal infection include prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, operative delivery, and retained placental fragments. This client is not at increased risk for puerperal infection based on the information given.
Choice D reason: Uterine atony is a condition where the uterus fails to contract and retract after delivery and can cause excessive bleeding, hypovolemic shock, and hemorrhage. The risk factors for uterine atony include overdistension of the uterus, prolonged labor, oxytocin use, anesthesia, and trauma. This client is at increased risk for uterine atony due to the large size of the newborn, which can overstretch the uterus and impair its ability to contract.
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