a client in active labor is admitted with preeclampsia which assessment finding is most significant in planning this clients care
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Nursing Elites

HESI RN

Maternity HESI Quizlet

1. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

2. The healthcare provider is preparing to suture a 10-year-old with a lacerated forehead. Both parents and the 12-year-old sibling are at the child’s bedside. Which instruction best supports the family?

Correct answer: D

Rationale: Choice D is the best instruction as it involves the family in the decision-making process, allowing them to choose who will stay with the child during the suturing procedure. This approach supports the family's comfort and participation in the child's care, promoting a sense of control and family-centered care. Choices A, B, and C do not promote family involvement and may lead to feelings of exclusion or lack of control among the family members.

3. What action should be implemented when preparing to measure the fundal height of a pregnant client?

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

4. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

5. A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?

Correct answer: C

Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus. Choices A, B, and D are important in labor assessment, but in this scenario, the most crucial information needed is the date of the last normal menstrual period to estimate the gestational age.

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