, PN MATERNAL NEWBORN 2025
EDITION
A nurse provides home care instructions to a client with mild preeclampsia. The
nurse tells the clientthat:
A) Sodium intake is restricted
B) Fluid intake must be limited to 1 quart each day
C) Urine output must be measured and that the physician should be notified if
output is less than 500mL in a 24-hour period
D) Urinary protein must be measured and that the physician should be notified if
the results indicate atrace amount of protein
ANS: C
Feedback: INCORRECT
Rationale: Preeclampsia is considered mild when the diastolic blood pressure does
not exceed 100 mmHg,
proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache,
visual
disturbances, and abdominal pain are absent. The diet should provide ample protein
and calories, andfluid
and sodium should not be limited. The disease is considered severe when the blood
pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or
more), and oliguria is present (500 mLor less in 24 hours). Therefore, urine output
of less than 500 mL/24 hr should prompt the client to notify the physician.
Test-Taking Strategy: Use the process of elimination. Thinking about the
nutritional needs of thepregnant
client will assist you in eliminating the options addressing sodium and fluid intake. To
select from the
,remaining options, focus on the client’s diagnosis, mild preeclampsia, and recall that
a trace amount of
protein is expected. Review home care measures for the client with mild
preeclampsia if you haddifficulty
with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-
child nursing (3rd ed., p.628). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Physiological
Integrity Integrated Process:
Teaching and LearningContent
Area: Maternity/Antepartum
Points Earned: 0.0/1.0
Correct Answer(s): C
.
A nurse is monitoring a hospitalized client who is being treated for preeclampsia.
Which items of thefollowing information elicited during the assessment indicate
that the condition has not yet resolved?
Type the option number that is the correct answer.
Answer:
Nursing Progress Notes
1. Hyperreflexia is present.
2. Urinary protein is not detectable.
3. Urine output is 45 mL/hr.
4. Blood pressure is 128/78
mm Hg.ANS: 1
Feedback: INCORRECT
Rationale: Hypertension, generalized edema, and proteinuria are the three classic
signs of preeclampsia. Deep tendon reflexes may be very brisk (hyperreflexia) and
clonus may be present, suggesting cerebral irritability resulting from decreased
brain circulation and edema. Decreased urinary output (less than 30 mL/hr)
indicates poor perfusion of the kidneys and may precede acute renal failure.
Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a
blood pressure of 128/78 mm Hg are all signs
, that preeclampsia is resolving.
Test-Taking Strategy: Use the process of elimination and note the strategic words "has
not yet resolved."This indicates that you must look for the option that is a sign or
symptom of preeclampsia. Eliminate the
options that are comparable or alike in that they identify normal findings. Review
the signs andsymptoms
of preeclampsia if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-
child nursing (3rd ed., pp.623, 624). St. Louis: Elsevier.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Points Earned: 0.0/1.0
Correct Answer(s): 1
.
A nurse is caring for a client who sustained a missed abortion during the second
trimester of pregnancy.For which finding indicating the need for further evaluation
does the nurse monitor the client?
A) Spontaneous bruising
B) Decrease in uterine size
C) Urine output of 30 mL/hr
D) Brownish vaginal
dischargeANS: A
Feedback: INCORRECT
Rationale: Missed abortion is the term used to describe when a fetus dies during the
first half of pregnancy but is retained in the uterus. When the fetus dies, the early
symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency)
disappear. The uterus stops growing and begins to shrink.Red or brownish vaginal
bleeding may or may not occur. A major complication of a missed abortion is
disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous
needle insertion or
EDITION
A nurse provides home care instructions to a client with mild preeclampsia. The
nurse tells the clientthat:
A) Sodium intake is restricted
B) Fluid intake must be limited to 1 quart each day
C) Urine output must be measured and that the physician should be notified if
output is less than 500mL in a 24-hour period
D) Urinary protein must be measured and that the physician should be notified if
the results indicate atrace amount of protein
ANS: C
Feedback: INCORRECT
Rationale: Preeclampsia is considered mild when the diastolic blood pressure does
not exceed 100 mmHg,
proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache,
visual
disturbances, and abdominal pain are absent. The diet should provide ample protein
and calories, andfluid
and sodium should not be limited. The disease is considered severe when the blood
pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or
more), and oliguria is present (500 mLor less in 24 hours). Therefore, urine output
of less than 500 mL/24 hr should prompt the client to notify the physician.
Test-Taking Strategy: Use the process of elimination. Thinking about the
nutritional needs of thepregnant
client will assist you in eliminating the options addressing sodium and fluid intake. To
select from the
,remaining options, focus on the client’s diagnosis, mild preeclampsia, and recall that
a trace amount of
protein is expected. Review home care measures for the client with mild
preeclampsia if you haddifficulty
with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-
child nursing (3rd ed., p.628). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Physiological
Integrity Integrated Process:
Teaching and LearningContent
Area: Maternity/Antepartum
Points Earned: 0.0/1.0
Correct Answer(s): C
.
A nurse is monitoring a hospitalized client who is being treated for preeclampsia.
Which items of thefollowing information elicited during the assessment indicate
that the condition has not yet resolved?
Type the option number that is the correct answer.
Answer:
Nursing Progress Notes
1. Hyperreflexia is present.
2. Urinary protein is not detectable.
3. Urine output is 45 mL/hr.
4. Blood pressure is 128/78
mm Hg.ANS: 1
Feedback: INCORRECT
Rationale: Hypertension, generalized edema, and proteinuria are the three classic
signs of preeclampsia. Deep tendon reflexes may be very brisk (hyperreflexia) and
clonus may be present, suggesting cerebral irritability resulting from decreased
brain circulation and edema. Decreased urinary output (less than 30 mL/hr)
indicates poor perfusion of the kidneys and may precede acute renal failure.
Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a
blood pressure of 128/78 mm Hg are all signs
, that preeclampsia is resolving.
Test-Taking Strategy: Use the process of elimination and note the strategic words "has
not yet resolved."This indicates that you must look for the option that is a sign or
symptom of preeclampsia. Eliminate the
options that are comparable or alike in that they identify normal findings. Review
the signs andsymptoms
of preeclampsia if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-
child nursing (3rd ed., pp.623, 624). St. Louis: Elsevier.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Points Earned: 0.0/1.0
Correct Answer(s): 1
.
A nurse is caring for a client who sustained a missed abortion during the second
trimester of pregnancy.For which finding indicating the need for further evaluation
does the nurse monitor the client?
A) Spontaneous bruising
B) Decrease in uterine size
C) Urine output of 30 mL/hr
D) Brownish vaginal
dischargeANS: A
Feedback: INCORRECT
Rationale: Missed abortion is the term used to describe when a fetus dies during the
first half of pregnancy but is retained in the uterus. When the fetus dies, the early
symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency)
disappear. The uterus stops growing and begins to shrink.Red or brownish vaginal
bleeding may or may not occur. A major complication of a missed abortion is
disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous
needle insertion or
