The nurse is monitoring a client with severe preeclampsia. What assessment finding requires immediate intervention?

Correct Answer: B

Rationale: In the context of severe preeclampsia, the assessment finding that requires immediate intervention is option B) Urine output of 25 mL/hr. This is because a decreased urine output can indicate declining renal function, which could progress to renal failure in severe cases of preeclampsia. In preeclampsia, there is a risk of developing HELLP syndrome, a condition characterized by hemolysis, elevated liver enzymes, and low platelet count, which can further worsen renal function. Option A) Blood pressure of 150/90 mmHg is elevated but not the most concerning finding in severe preeclampsia. However, it does require monitoring and potential intervention. Option C) Headache relieved by acetaminophen can be a symptom of preeclampsia but does not indicate an immediate threat to the client's health. It is important to address pain and discomfort in clients but not as urgent as addressing renal function. Option D) Deep tendon reflexes +2 are a typical finding in preeclampsia due to hyperreflexia. While this finding is associated with the condition, it is not as urgent as addressing renal impairment indicated by decreased urine output. In an educational context, understanding the priority assessments in clients with severe preeclampsia is crucial for nurses caring for pregnant individuals. Timely recognition and intervention can prevent serious complications such as eclampsia, placental abruption, and organ damage. Nurses must prioritize assessments based on the client's condition to provide safe and effective care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Macrosomia. Gestational diabetes increases the risk of delivering a macrosomic baby, which refers to a newborn significantly larger than average. This occurs because maternal hyperglycemia crosses the placenta, stimulating the baby's pancreas to produce extra insulin, leading to increased fetal growth. Macrosomia poses risks during delivery such as shoulder dystocia and birth injuries. Option A) Preterm labor is less likely in gestational diabetes compared to other maternal conditions like hypertension. Option B) Placenta previa is not directly associated with gestational diabetes. Option D) Abruptio placentae, while a serious complication, is not the most common risk in gestational diabetes. Educationally, understanding these complications is crucial for nurses caring for pregnant women with gestational diabetes. Proper management, monitoring, and education on blood sugar control can help reduce the risk of complications like macrosomia, ensuring better outcomes for both the mother and the newborn.

Correct Answer: C

Rationale: In the postpartum period, assessing a breastfeeding mother is crucial for early detection of any issues that may impact successful breastfeeding. In this scenario, the correct answer is C) Cracked and bleeding nipples, which requires further evaluation. This finding can indicate poor latch technique, improper positioning, or a possible fungal infection like thrush, all of which can lead to pain, difficulty breastfeeding, and potential nipple damage. Option A) Engorgement on day 3 postpartum is a common physiological response as milk production increases, usually resolving with proper breastfeeding techniques. Option B) Mild nipple tenderness can be expected initially but should improve with correct positioning and latch. Option D) Colostrum present in the first 48 hours is a positive sign of early milk production and is normal in the immediate postpartum period. Educationally, understanding these nuances helps nurses provide quality care to breastfeeding mothers by identifying and addressing issues promptly to support successful breastfeeding and maternal-infant bonding. Early intervention for cracked and bleeding nipples can prevent further complications and ensure a positive breastfeeding experience.

Correct Answer: C

Rationale: In the context of a client with hyperemesis gravidarum, a condition characterized by severe nausea, vomiting, weight loss, and electrolyte imbalances during pregnancy, the finding that requires immediate intervention is C) Dry mucous membranes and poor skin turgor. This finding indicates dehydration, a serious concern in pregnant women as it can lead to maternal and fetal complications. Dehydration can result in electrolyte imbalances, reduced blood volume, and decreased placental perfusion, putting both the mother and baby at risk. Immediate rehydration therapy is essential to prevent further complications. Option A) Urine output of 50 mL/hr is within the normal range for a pregnant woman, so it does not require immediate intervention. Option B) Weight loss of 5 pounds in 2 weeks, although concerning, is a common feature of hyperemesis gravidarum and may not warrant immediate intervention unless it is severe and accompanied by other critical symptoms. Option D) Nausea relieved by eating crackers is a common self-management strategy for nausea in pregnancy and does not indicate an immediate need for intervention. Educationally, this question highlights the importance of recognizing dehydration in pregnant women with hyperemesis gravidarum and the necessity of prompt intervention to prevent complications for both the mother and the fetus. Nurses need to be vigilant in assessing hydration status and responding promptly to signs of dehydration in this high-risk population.

Correct Answer: A

Rationale: In the case of a client at 34 weeks' gestation diagnosed with polyhydramnios, the nurse should monitor for the complication of preterm labor. Polyhydramnios, an excessive accumulation of amniotic fluid, can lead to uterine overdistension, which in turn can stimulate contractions and lead to preterm labor. Option A, preterm labor, is the correct answer due to the physiological relationship between polyhydramnios and uterine overdistension. Monitoring for signs of preterm labor, such as regular contractions or cervical changes, is crucial in this scenario to prevent premature birth and potential complications for the newborn. The other options are incorrect in this context: - Placental abruption (Option B) is more commonly associated with conditions like hypertension or trauma, not directly linked to polyhydramnios. - Fetal growth restriction (Option C) is usually associated with conditions like preeclampsia or placental insufficiency rather than polyhydramnios. - Cord prolapse (Option D) is more likely to occur in cases of polyhydramnios during labor or delivery, not as a direct complication that the nurse would monitor for during pregnancy at 34 weeks' gestation. Understanding these associations between polyhydramnios and potential complications is crucial for nurses caring for pregnant clients to provide appropriate monitoring and interventions to ensure optimal maternal and fetal outcomes.