Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
A. Complaints of feeling hot when the room is cold.
Feeling hot when the room is cold is not a typical sign or complication of severe preeclampsia. This symptom is more related to general temperature sensitivity and does not indicate the hematologic or vascular complications associated with preeclampsia.
B. Evidence of bleeding, such as in gums, petechiae, and purpura.
Evidence of bleeding, including gums bleeding, petechiae, and purpura, may indicate thrombocytopenia or a progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. These findings suggest impaired coagulation and increased risk of bleeding, which are life-threatening if not promptly managed. Monitoring for such hematologic complications is essential in severe preeclampsia.
C. Edema of the lower extremities.
Edema of the lower extremities is common in normal pregnancy and mild preeclampsia, but it is not a specific sign of a serious complication. While generalized edema can indicate worsening preeclampsia, isolated lower-extremity edema is not as closely associated with life-threatening complications as bleeding or hematologic abnormalities.
D. Periods of fetal movement followed by quiet periods.
Periods of fetal movement followed by quiet periods are typical fetal behavior and do not indicate a maternal complication of preeclampsia. Monitoring for changes in fetal movement is important, but this finding alone does not reflect maternal complications of severe preeclampsia.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Demsn 650 Pediatrics Proctored Exam. Take the full exam now
Full Explanation
A. Feeling hot when the room is cold is not a typical sign or complication of severe preeclampsia. This symptom is more related to general temperature sensitivity and does not indicate the hematologic or vascular complications associated with preeclampsia.
B. Evidence of bleeding, including gums bleeding, petechiae, and purpura, may indicate thrombocytopenia or a progression toward HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe complication of preeclampsia. These findings suggest impaired coagulation and increased risk of bleeding, which are life-threatening if not promptly managed. Monitoring for such hematologic complications is essential in severe preeclampsia.
C. Edema of the lower extremities is common in normal pregnancy and mild preeclampsia, but it is not a specific sign of a serious complication. While generalized edema can indicate worsening preeclampsia, isolated lower-extremity edema is not as closely associated with life-threatening complications as bleeding or hematologic abnormalities.
D. Periods of fetal movement followed by quiet periods are typical fetal behavior and do not indicate a maternal complication of preeclampsia. Monitoring for changes in fetal movement is important, but this finding alone does not reflect maternal complications of severe preeclampsia.
Similar Questions
A nurse is reviewing the provider's plan of care for an 8-year-old child whose height has dropped from the 25th percentile to the 5th percentile over the past year. The parents ask what test can help determine whether their child's bone growth is delayed. Which diagnostic test should the nurse anticipate?
A. Routine abdominal ultrasound
A routine abdominal ultrasound is not used to assess bone age or growth delays. While abdominal ultrasounds can detect organ abnormalities, they provide no information about skeletal maturation.
B. Complete blood count (CBC)
A complete blood count (CBC) evaluates blood cell levels and can detect anemia or infection, but it does not provide information about bone growth or skeletal development.
C. Hand-wrist X-ray
A hand-wrist X-ray is the standard diagnostic test to assess bone age and skeletal maturation. By comparing the X-ray of the child’s hand and wrist bones to standardized age-related charts (such as the Greulich and Pyle atlas), providers can determine if the child’s skeletal growth is appropriate for chronological age. This helps identify growth delays, endocrine disorders, or other conditions affecting stature.
D. Anthropometric hand-wrist measurement
Anthropometric hand-wrist measurement refers to physical measurements of the hand and wrist, which do not provide sufficient information to determine bone age or detect growth delays. X-ray imaging is required for accurate assessment of skeletal maturity.
Full Explanation
A. A routine abdominal ultrasound is not used to assess bone age or growth delays. While abdominal ultrasounds can detect organ abnormalities, they provide no information about skeletal maturation.
B. A complete blood count (CBC) evaluates blood cell levels and can detect anemia or infection, but it does not provide information about bone growth or skeletal development.
C. A hand-wrist X-ray is the standard diagnostic test to assess bone age and skeletal maturation. By comparing the X-ray of the child’s hand and wrist bones to standardized age-related charts (such as the Greulich and Pyle atlas), providers can determine if the child’s skeletal growth is appropriate for chronological age. This helps identify growth delays, endocrine disorders, or other conditions affecting stature.
D. Anthropometric hand-wrist measurement refers to physical measurements of the hand and wrist, which do not provide sufficient information to determine bone age or detect growth delays. X-ray imaging is required for accurate assessment of skeletal maturity.
A nurse is teaching a parent about normal infant growth and development. Which statement by the parent indicates they can apply developmental principles correctly to their own child?
A. "All babies reach milestones at the exact same age"
Developmental milestones follow predictable sequences, but the exact age at which each child reaches them can vary. Expecting all babies to reach milestones at the same age is unrealistic and does not reflect normal variation in growth and development.
B. "Once my baby starts walking, fine motor skills will develop automatically"
While gross motor skills like walking often develop alongside fine motor skills, fine motor development does not occur automatically. It requires practice, coordination, and maturation of muscles and nervous system pathways.
C. "Genetics don't influence my baby's growth"
Genetics play a significant role in growth, influencing height, weight, body proportions, and sometimes developmental timing. Denying the influence of genetics misrepresents a key factor in growth and development.
D. "My baby's growth and skills follow predictable patterns, but may happen at different times"
This statement reflects an accurate understanding of developmental principles. Growth and developmental milestones occur in a predictable sequence (cephalocaudal, proximodistal, and simple-to-complex patterns), but the timing can vary for each child. This acknowledges normal individual differences while recognizing typical developmental patterns.
Full Explanation
A. Developmental milestones follow predictable sequences, but the exact age at which each child reaches them can vary. Expecting all babies to reach milestones at the same age is unrealistic and does not reflect normal variation in growth and development.
B. While gross motor skills like walking often develop alongside fine motor skills, fine motor development does not occur automatically. It requires practice, coordination, and maturation of muscles and nervous system pathways.
C. Genetics play a significant role in growth, influencing height, weight, body proportions, and sometimes developmental timing. Denying the influence of genetics misrepresents a key factor in growth and development.
D. This statement reflects an accurate understanding of developmental principles. Growth and developmental milestones occur in a predictable sequence (cephalocaudal, proximodistal, and simple-to-complex patterns), but the timing can vary for each child. This acknowledges normal individual differences while recognizing typical developmental patterns.
A 6-month-old infant is able to lift the head while lying on the stomach, then roll over, and eventually sit with support. This sequence BEST demonstrates which principle of growth and development?
A. Differentiation
Differentiation refers to the progression from simple, global behaviors to more complex, specific skills, such as grasping with fingers instead of the whole hand. While differentiation occurs during development, the sequence described focuses on head-to-toe progression, not skill refinement.
B. Proximodistal development
Proximodistal development describes growth and skill acquisition from the center of the body outward (e.g., control of the trunk before the hands and fingers). The sequence in this example emphasizes head and upper body control first, not central-to-peripheral development.
C. Individual differences
Individual differences refer to the variations in the timing and rate at which children reach developmental milestones. While relevant, this principle does not explain the specific head-to-toe progression demonstrated.
D. Cephalocaudal development
Cephalocaudal development refers to growth and motor control that progresses from head to tail (top to bottom). The infant first gains control of the head and neck, then the upper body, and later the lower body and sitting posture. This head-to-toe pattern of motor development is exemplified by lifting the head, rolling over, and sitting with support.
Full Explanation
A. Differentiation refers to the progression from simple, global behaviors to more complex, specific skills, such as grasping with fingers instead of the whole hand. While differentiation occurs during development, the sequence described focuses on head-to-toe progression, not skill refinement.
B. Proximodistal development describes growth and skill acquisition from the center of the body outward (e.g., control of the trunk before the hands and fingers). The sequence in this example emphasizes head and upper body control first, not central-to-peripheral development.
C. Individual differences refer to the variations in the timing and rate at which children reach developmental milestones. While relevant, this principle does not explain the specific head-to-toe progression demonstrated.
D. Cephalocaudal development refers to growth and motor control that progresses from head to tail (top to bottom). The infant first gains control of the head and neck, then the upper body, and later the lower body and sitting posture. This head-to-toe pattern of motor development is exemplified by lifting the head, rolling over, and sitting with support.