Nokea
A client at 38 weeks of gestation with a diagnosis of preeclampsia has the following findings. Which of the following should the nurse identify as inconsistent with preeclampsia?
- A. 1+ pitting sacral edema
- B. 3+ protein in the urine
- C. Blood pressure 148/98 mm Hg
- D. Deep tendon reflexes of +1
Correct Answer: D
Rationale: The correct answer is D, Deep tendon reflexes of +1. In preeclampsia, deep tendon reflexes are typically hyperactive, not diminished (+1). This indicates hyporeflexia, which is inconsistent with preeclampsia. A is consistent with preeclampsia, as mild edema is common. B is also consistent, as proteinuria is a hallmark sign. C is consistent, as elevated blood pressure is a key feature. Therefore, D is the only choice that does not align with the expected findings in preeclampsia.
You may also like to solve these questions
While observing the electronic fetal heart rate monitor tracing for a client at 40 weeks of gestation in labor, a nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
- A. Early decelerations
- B. Accelerations
- C. Late decelerations
- D. Variable decelerations
Correct Answer: D
Rationale: The correct answer is D: Variable decelerations. Variable decelerations are abrupt decreases in the fetal heart rate that coincide with contractions, indicating umbilical cord compression. This pattern can lead to fetal hypoxia and distress. Early decelerations (A) are gradual decreases in heart rate that mirror contractions and are considered benign. Accelerations (B) are increases in heart rate and are a reassuring sign of fetal well-being. Late decelerations (C) are gradual decreases in heart rate that occur after the peak of a contraction, indicating uteroplacental insufficiency.
A client is learning how to check basal temperature to determine ovulation. When should the client check her temperature?
- A. On days 13 to 17 of her menstrual cycle
- B. Every morning before arising
- C. 1 hour following intercourse
- D. Before going to bed every night
Correct Answer: B
Rationale: The correct answer is B: Every morning before arising. This is because basal body temperature is the lowest body temperature attained during rest, typically just before waking up. Checking the temperature at this time provides the most accurate measurement of basal temperature. Options A, C, and D are incorrect because ovulation typically occurs around 14 days before the start of the next menstrual period, not on days 13 to 17 specifically (A), 1 hour following intercourse is not a reliable indicator of ovulation (C), and basal temperature should be checked in the morning, not before going to bed at night (D).
A parent of a newborn is being taught about crib safety. Which statement by the client indicates understanding of the teaching?
- A. I will place my baby on his stomach when he is sleeping.
- B. I should remove extra blankets from my baby's crib.
- C. I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps.
- D. I should place my baby's crib next to the heater to keep him warm during the winter.
Correct Answer: B
Rationale: The correct answer is B because removing extra blankets from the baby's crib reduces the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby on the stomach (Option A) increases the risk of SIDS. Padding the mattress (Option C) can also increase the risk of suffocation. Placing the crib next to a heater (Option D) can lead to overheating and poses a fire hazard. Removing extra blankets ensures a safe sleep environment for the baby.
During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?
- A. Poor sucking
- B. Blue discoloration of the hands and feet
- C. Soft, edematous area on the scalp
- D. Facial edema
Correct Answer: A
Rationale: The correct answer is A: Poor sucking. This finding is concerning as it may indicate potential issues with feeding and nutrition in the newborn, which can lead to complications. Poor sucking can be a sign of various underlying problems that require prompt intervention. Blue discoloration of the hands and feet (choice B) is likely due to peripheral cyanosis, which is common in newborns and often resolves on its own. Soft, edematous area on the scalp (choice C) is a common finding in newborns after vacuum-assisted delivery and typically resolves without intervention. Facial edema (choice D) is also a common finding in newborns after delivery and typically resolves on its own.
A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?
- A. It's a minor inconvenience, which you should ignore.
- B. In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone.
- C. There is no way to predict how long it will last in each individual client.
- D. It occurs during the first trimester and near the end of the pregnancy.
Correct Answer: D
Rationale: The correct answer is D because urinary frequency is common in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus. This symptom typically improves by the end of the first trimester, as the uterus rises and reduces pressure on the bladder. Therefore, telling the client that it occurs during the first trimester and near the end of pregnancy is accurate.
Choice A is incorrect because urinary frequency should not be ignored as it could be a sign of a urinary tract infection or other underlying issue.
Choice B is incorrect because it inaccurately suggests that urinary frequency only lasts until the 12th week and implies that poor bladder tone is the sole factor influencing this symptom.
Choice C is incorrect because while it is true that individual experiences can vary, there are general patterns and timelines for common pregnancy symptoms like urinary frequency.