a primigravida is being monitored at the prenatal clinic for preeclampsia which finding is of greatest concern to the nurse

HESI LPN

HESI Maternal Newborn

1. A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

A. Blood pressure (BP) increased to 138/86 mm Hg.
B. Weight gain of 0.5 kg during the past 2 weeks.
C. Dipstick value of 3+ for protein in her urine.
D. Pitting pedal edema at the end of the day.

Correct answer: C

Rationale: The correct answer is C. Proteinuria, indicated by a dipstick value of 3+ in the urine, is a significant concern in a patient being monitored for preeclampsia. Proteinuria is a key diagnostic criterion for preeclampsia, and a value of 3+ signifies a substantial amount of protein in the urine, warranting further evaluation. While an increase in blood pressure to 138/86 mm Hg is slightly elevated, it does not meet the diagnostic threshold for severe hypertension in preeclampsia. A weight gain of 0.5 kg over 2 weeks is within normal limits and not as concerning as significant rapid weight gain. Pitting pedal edema, though common in pregnancy, is not a specific indicator of preeclampsia and is considered a less concerning finding compared to significant proteinuria.

2. Twins that derive from a single zygote that has split into two are called:

A. monozygotic (MZ) twins.
B. fraternal twins.
C. non-identical twins.
D. dizygotic (DZ) twins.

Correct answer: A

Rationale: The correct answer is A: monozygotic (MZ) twins. Monozygotic twins, also known as identical twins, occur when a single zygote splits into two embryos, leading to two genetically identical individuals. Choice B, fraternal twins, are twins that develop from two separate eggs fertilized by two different sperm cells, resulting in non-identical siblings. Choice C, non-identical twins, is not a common term used to describe this type of twinning. Choice D, dizygotic (DZ) twins, refer to twins that develop from two separate eggs fertilized by two different sperm cells, leading to non-identical twins.

3. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?

A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

Correct answer: B

Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.

4. A woman has experienced iron deficiency anemia during her pregnancy. She had been taking iron for 3 months before the birth. The client gave birth by cesarean 2 days earlier and has been having problems with constipation. After assisting her back to bed from the bathroom, the nurse notes that the woman’s stools are dark (greenish-black). What should the nurse’s initial action be?

A. Perform a guaiac test and record the results.
B. Recognize the finding as abnormal and report it to the primary health care provider.
C. Recognize the finding as a normal result of iron therapy.
D. Check the woman’s next stool to validate the observation.

Correct answer: C

Rationale: The nurse should recognize that dark stools are a common side effect in clients who are taking iron replacement therapy. Dark stools are a known, expected result of iron supplementation and are not indicative of a complication unless other symptoms of GI bleeding are present. A guaiac test would be necessary if there were concerns about gastrointestinal bleeding. Recognizing dark stools as a consequence of iron therapy is an essential nursing assessment skill and does not require immediate reporting. Checking the next stool to confirm the observation is unnecessary as the presence of dark stools in this context is already an expected outcome of iron supplementation.

5. A new parent is receiving discharge teaching about car seat safety from a nurse. Which statement by the parent indicates an understanding of the teaching?

A. “I should position my baby’s car seat at a 45-degree angle in the car.”
B. “I should place the car seat rear-facing until my baby is 12 months old.”
C. “I should place the harness snugly in a slot above my baby’s shoulders.”
D. “I should position the retainer clip at the top of my baby’s abdomen.”

Correct answer: A

Rationale: The correct answer is A. Positioning the car seat at a 45-degree angle is crucial to prevent the baby's head from falling forward, which can obstruct the airway. Choice B is incorrect because the recommendation is to keep the car seat rear-facing until the baby reaches the height or weight limit set by the car seat manufacturer, typically beyond 12 months. Choice C is incorrect as the harness should be snugly placed at or below the baby's shoulders, not above. Choice D is incorrect as the retainer clip should be positioned at armpit level to secure the harness straps properly.