The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding?

Correct Answer: A

Rationale: In the context of mild preeclampsia, bed rest is often recommended to manage the condition and reduce the risk of complications. Weight loss would be considered a positive finding when evaluating the effectiveness of bed rest because it may indicate a reduction in edema, which is a common symptom of preeclampsia. Weight loss can also suggest a decrease in fluid retention and potentially improved circulation, which are beneficial in managing preeclampsia. Option B, 2+ proteinuria, is an indicator of renal involvement in preeclampsia and would not be considered a positive finding when evaluating the effectiveness of bed rest. It suggests ongoing kidney damage and the progression of the disease. Option C, decrease in plasma protein, is not a typical parameter used to evaluate the effectiveness of bed rest in managing mild preeclampsia. While preeclampsia can affect plasma proteins, it is not a direct measure of the response to bed rest. Option D, 3+ patellar reflexes, is not relevant to assessing the effectiveness of bed rest for preeclampsia. Increased deep tendon reflexes may indicate conditions like hyperthyroidism or neurological issues but are not specific to preeclampsia management. In an educational context, understanding the rationale behind monitoring specific signs and symptoms in preeclampsia is crucial for nurses caring for pregnant women. Recognizing positive and negative findings helps nurses make informed decisions about patient care and treatment interventions.

Correct Answer: C

Rationale: In the assessment of clonus in a client with severe preeclampsia, the correct action for the nurse to perform is to dorsiflex the woman's foot (Option C). Clonus is characterized by repetitive, rhythmic contractions and relaxations of a muscle. By dorsiflexing the foot, the nurse can elicit this response in the client, which is indicative of neurological hyperactivity associated with conditions like preeclampsia. Option A, striking the woman's patellar tendon, is incorrect as this action tests for deep tendon reflexes, not clonus. Palpating the woman's ankle (Option B) does not elicit a response related to clonus. Positioning the woman's feet flat on the floor (Option D) is also not directly related to assessing clonus. Educationally, understanding the specific assessment techniques for conditions like preeclampsia is crucial for nurses caring for pregnant clients. Proper assessment skills can help in early detection of complications, leading to timely interventions and improved outcomes for both the mother and the baby. Practicing and mastering these assessment techniques is vital for providing safe and effective care in maternal health settings.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Papilledema. Papilledema is a classic sign of severe preeclampsia, indicating increased intracranial pressure due to cerebral edema. This condition can lead to visual disturbances and is a critical indicator of worsening preeclampsia that requires immediate intervention to prevent seizures and other serious complications. Option A) Fundal height of 32 cm is not directly related to the presentation of severe preeclampsia. Fundal height is typically used to assess fetal growth and gestational age. Option C) Patellar reflexes of +2 are a normal finding and not specific to the clinical manifestations of severe preeclampsia. Option D) Nystagmus is not a typical sign of severe preeclampsia and is more commonly associated with neurological or vestibular disorders. Educationally, understanding the signs and symptoms of severe preeclampsia is crucial for healthcare providers caring for pregnant women. Recognizing these signs promptly can help prevent maternal and fetal complications. Regular monitoring and assessment are essential components of prenatal care to detect and manage conditions like severe preeclampsia effectively.

Correct Answer: B

Rationale: In the context of maternal diseases during pregnancy, understanding the causes of pathologic hyperbilirubinemia is crucial for healthcare providers to provide optimal care to pregnant individuals and their babies. The correct answer is B) Hemolytic disorders. Hemolytic disorders, such as Rh incompatibility or ABO incompatibility, can lead to the destruction of red blood cells in the fetus, resulting in an increased production of bilirubin. This excess bilirubin can overwhelm the baby's liver's ability to process it, leading to pathologic hyperbilirubinemia. Option A) Hepatic disease is incorrect because while liver dysfunction can contribute to elevated bilirubin levels, it is not the most common cause during pregnancy. Option C) Postmaturity is incorrect as it refers to a condition where a pregnancy extends beyond 42 weeks, which can increase the risk of complications but is not directly related to hyperbilirubinemia. Option D) Congenital heart defect is incorrect as it does not typically cause pathologic hyperbilirubinemia in the newborn. Educationally, understanding the etiology of pathologic hyperbilirubinemia in newborns allows healthcare providers to identify at-risk infants promptly and provide appropriate monitoring and treatment to prevent complications such as kernicterus. This knowledge is vital for nurses, midwives, and physicians involved in maternal-fetal care to ensure positive outcomes for both the mother and the baby.

Correct Answer: D

Rationale: In the case of a newborn diagnosed with a diaphragmatic hernia, the most appropriate nursing diagnosis is "D) Reduced gas exchange." This is the correct answer because a diaphragmatic hernia can lead to compression of the lungs, impacting the newborn's ability to exchange oxygen and carbon dioxide efficiently. This can result in respiratory distress and hypoxemia, making it crucial for nurses to prioritize interventions that support optimal gas exchange. Option A, "Potential for impaired parent-infant attachment," may be relevant in other situations but is not the priority in this case where the newborn's physiological needs take precedence. Option B, "Inadequate nutrition," is not directly related to the immediate concern of gas exchange. Option C, "Potential for infection," is important to consider but is not the most immediate concern compared to the compromised gas exchange in a newborn with a diaphragmatic hernia. Educationally, understanding the prioritization of nursing diagnoses based on the newborn's condition is crucial in providing safe and effective care. By focusing on the most critical issue, nurses can intervene promptly to support the newborn's respiratory function and overall well-being. This rationale highlights the importance of clinical judgment and critical thinking in nursing practice, especially in neonatal care settings.