What important, immediate postoperative care practice should the nurse remember when caring for a woman who has had a mastectomy?

Choice A reason: Seizure activity and hypotension are not signs and symptoms of severe preeclampsia, but rather of eclampsia, which is a life-threatening complication of preeclampsia. Eclampsia is characterized by convulsions and coma, and it requires immediate treatment to prevent maternal and fetal death.

Choice B reason: Platelet count of less than 100,000/mm3 and visual problems are signs and symptoms of severe preeclampsia, as they indicate hematologic and neurologic complications. Severe preeclampsia can cause thrombocytopenia, which is a low platelet count that increases the risk of bleeding. It can also cause cerebral edema, which can impair the vision and cause blurred vision, spots, or flashes of light.

Choice C reason: Ankle clonus and epigastric pain are signs and symptoms of severe preeclampsia, as they indicate neuromuscular and hepatic complications. Severe preeclampsia can cause hyperreflexia, which is an exaggerated reflex response that can be elicited by dorsiflexing the ankle and observing rhythmic jerking of the foot. It can also cause liver damage, which can manifest as epigastric pain or right upper quadrant pain.

Choice D reason: Decreased urinary output and irritability are signs and symptoms of severe preeclampsia, as they indicate renal and central nervous system complications. Severe preeclampsia can cause oliguria, which is a reduced urine output of less than 500 mL in 24 hours. It can also cause increased intracranial pressure, which can affect the mood and behavior and cause irritability, anxiety, or confusion.

Choice E reason: Transient headache and +1 proteinuria are not signs and symptoms of severe preeclampsia, but rather of mild preeclampsia, which is a less severe form of the condition. Mild preeclampsia is characterized by blood pressure of 140/90 mm Hg or higher, proteinuria of 1+ or higher, and mild edema. It does not cause severe complications or organ damage, but it can progress to severe preeclampsia if not treated.

Choice A reason: A fetal heartbeat auscultated with a Doppler or a fetoscope is a positive sign of pregnancy, as it confirms the presence of a living fetus in the uterus. A Doppler is an electronic device that uses sound waves to detect the fetal heart rate, while a fetoscope is a stethoscope-like instrument that amplifies the fetal heart sounds. The fetal heartbeat can be heard as early as 10 to 12 weeks of gestation with a Doppler and 18 to 20 weeks of gestation with a fetoscope.

Choice B reason: Quickening is the first perception of fetal movement by the pregnant woman, usually felt between 16 and 20 weeks of gestation for first-time mothers and 13 to 16 weeks of gestation for experienced mothers. However, quickening is not a positive sign of pregnancy, as it can be subjective and mistaken for other sensations, such as gas, hunger, or muscle spasms².

Choice C reason: Morning sickness is a common symptom of pregnancy that involves nausea and vomiting, usually in the first trimester. However, morning sickness is not a positive sign of pregnancy, as it can be caused by other factors, such as food poisoning, stress, or medication.

Choice D reason: A positive pregnancy test is a probable sign of pregnancy, not a positive sign. A pregnancy test detects the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the urine or blood of the woman. However, a positive pregnancy test does not guarantee a viable pregnancy, as it can be influenced by the timing, the quality, or the interpretation of the test. A positive pregnancy test can also occur in cases of ectopic pregnancy, molar pregnancy, or miscarriage.