The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?

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VATI Maternal Newborn Assessment Questions

Question 1 of 5

The nurse is assessing a client with suspected preeclampsia. What symptom supports this diagnosis?

Correct Answer: B

Rationale: In the context of pharmacology and maternal newborn assessment, understanding the symptoms of preeclampsia is crucial for providing safe and effective care to pregnant clients. The correct answer to the question is B) Proteinuria. Proteinuria, the presence of excess protein in the urine, is a hallmark sign of preeclampsia. It indicates kidney damage, which is a common complication of this condition. Monitoring for proteinuria is essential in the assessment and management of preeclampsia to prevent severe complications for both the mother and the fetus. Option A) Hyperglycemia is not typically associated with preeclampsia. While gestational diabetes can occur in pregnancy, it is a separate condition that involves elevated blood sugar levels, not protein in the urine. Option C) Increased fetal movement is not a symptom of preeclampsia. Fetal movement can vary throughout pregnancy and can be influenced by various factors, but it is not a diagnostic criterion for preeclampsia. Option D) Hypotension, or low blood pressure, is also not a typical symptom of preeclampsia. In fact, hypertension, rather than hypotension, is a key feature of preeclampsia, along with proteinuria and other signs such as edema and organ dysfunction. Educationally, understanding the specific symptoms and diagnostic criteria for preeclampsia is essential for nurses caring for pregnant clients. Proper assessment, early recognition, and timely intervention are crucial in managing preeclampsia to prevent complications such as eclampsia and adverse outcomes for both the mother and the baby. This knowledge equips nurses with the skills to provide comprehensive care and support to pregnant clients at risk for or diagnosed with preeclampsia.

Question 2 of 5

The nurse is monitoring a client with suspected placental abruption. What is a key assessment finding?

Correct Answer: B

Rationale: In the context of pharmacology, understanding key assessment findings in obstetric emergencies like placental abruption is crucial for safe and effective nursing care. The correct answer, option B - hard, rigid abdomen with severe pain, is a key assessment finding in placental abruption due to the abrupt separation of the placenta from the uterine wall, leading to significant maternal and fetal risks. This finding indicates internal bleeding, resulting in a tense, painful abdomen due to blood accumulation. Immediate recognition of this sign is vital to prevent maternal shock and fetal distress. Option A - painless vaginal bleeding, is incorrect because placental abruption typically presents with painful bleeding. Painless vaginal bleeding is more commonly associated with conditions like placenta previa. Option C - clear amniotic fluid, is incorrect as it does not specifically relate to the assessment finding in placental abruption. Clear amniotic fluid is indicative of intact fetal membranes, not a placental emergency. Option D - regular uterine contractions, is incorrect as placental abruption is more commonly associated with hypertonic, non-reassuring contractions or even uterine tetany rather than regular contractions. Educationally, this question highlights the importance of thorough assessment skills in recognizing critical signs of obstetric emergencies like placental abruption. Nurses must be able to differentiate between various clinical presentations to provide timely and appropriate interventions, emphasizing the significance of continuous monitoring and prompt action in maternal and fetal well-being.

Question 3 of 5

The nurse is assessing a client at 36 weeks' gestation who reports swelling in the hands and face. What is the priority nursing action?

Correct Answer: A

Rationale: In the context of pharmacology and maternal newborn assessment, the priority nursing action when assessing a client at 36 weeks' gestation who reports swelling in the hands and face is to check the client's blood pressure (Option A). This is crucial because sudden or severe swelling can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine that can lead to harmful complications for both the mother and the baby. Monitoring blood pressure allows for early detection and timely intervention to prevent adverse outcomes. Option B, reassuring the client that swelling is normal, is incorrect as it overlooks the potential seriousness of the situation and fails to address the need for further assessment. Option C, encouraging the client to reduce salt intake, while generally good advice for swelling, is not the priority in this scenario where preeclampsia needs to be ruled out. Option D, evaluating the fetal heart rate, is important but not the most immediate concern when potential preeclampsia is present. In the educational context, understanding the significance of assessing for signs of preeclampsia during pregnancy is essential for providing safe and effective care to expectant mothers. Nurses need to prioritize actions that address potential complications promptly to ensure the well-being of both the mother and the baby. This scenario highlights the importance of thorough assessment and critical thinking in maternity care, where quick decision-making can impact outcomes significantly.

Question 4 of 5

A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select one that does not that apply.

Correct Answer: C

Rationale: The best sites for applying the contraceptive patch are the buttocks, arm, and leg. These areas have sufficient fat and are away from areas that might rub off the patch. Choice B (Neck) is incorrect as the neck is not recommended for patch application due to the potential for irritation and the high blood flow area. Choice C (Breast) is not recommended because the breast tissue may affect the adhesion of the patch.

Question 5 of 5

A patient is taking oral contraceptives and asks whether they will still be effective if she has diarrhea. What should the nurse respond?

Correct Answer: B

Rationale: Diarrhea can reduce the absorption of oral contraceptives, potentially making them less effective. Choice A is incorrect because food does not always affect oral contraceptive absorption. Choice C is incorrect because there is no need to stop the contraceptives, but additional methods may be recommended during diarrhea. Choice D is incorrect because diarrhea does not increase the effectiveness of oral contraceptives.

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