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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: This statement is insensitive and dismissive, as it implies that the client's feelings are not valid or important. The nurse should not minimize the client's disappointment or guilt, but rather acknowledge and respect them.

Choice B reason: This statement is inaccurate and irrelevant, as it does not address the client's emotional needs or concerns. The nurse should not give false or misleading information, or focus on the physical aspects of recovery, but rather provide emotional support and education.

Choice C reason: This statement is presumptuous and unrealistic, as it assumes that the client wants or can have another pregnancy, and that a vaginal delivery is possible or preferable. The nurse should not make assumptions or promises, or compare different modes of delivery, but rather explore the client's feelings and expectations.

Choice D reason: This statement is empathetic and respectful, as it reflects the client's feelings and validates them. The nurse should use active listening and therapeutic communication skills, such as open-ended questions, clarifications, and summarizations, to help the client cope and express her emotions.

A. Prone positioning facilitates bone alignment. B. No special treatment is necessary. C. The shoulder should be immobilized and cast applied. D. Parents should be taught range-of-motion exercises.

Correct Answer is B

Explanation

The correct answer is B. No special treatment is necessary.

Choice A reason: Prone positioning is not typically recommended for a fractured clavicle in infants. It does not facilitate bone alignment in the case of clavicle fractures and is not part of standard care.

Choice B reason: This is the correct choice because clavicle fractures in newborns generally heal on their own without the need for special treatment. Parents may be instructed to pin the child’s sleeve to the front of their clothing to avoid moving the arm while it heals, but beyond gentle handling, no other special treatment is necessary. In most cases, clavicle fractures in newborns heal very quickly without any problems, and usually, no treatment is required.

Choice C reason: Immobilization and casting are not standard care for newborn clavicle fractures. These fractures typically heal without such interventions, and immobilization with a cast is not needed for these types of injuries in infants.

Choice D reason: While range-of-motion exercises might be beneficial later in the healing process, they are not the primary consideration immediately after the fracture occurs. The initial care plan focuses on gentle handling and comfort for the infant, not on exercises.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant's care?

Correct Answer is B

Explanation

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has been diagnosed with hyperemesis gravidarum. Which of the following is not a risk factor for hyperemesis gravidarum?

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?