Author Question: The nurse identifies the following assessment findings on a patient with pre-eclampsia: blood ... (Read 138 times)

soccerdreamer_17 · **on:** Jun 28, 2018

The nurse identifies the following assessment findings on a patient with pre-eclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet.

On the next hourly assessment, which of the following new assessment findings would be an indication of worsening of the pre-eclampsia?
1. Blood pressure 158/104
2. Urinary output 20 mL/hour
3. Reflexes 21
4. Platelet count 150,000

Question 2

While preparing a class on maternal-fetal ABO incompatibility for antepartum patients, the nurse is creating a brochure. Which statement should be included in the brochure information?

1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus.
2. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.
3. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus.
4. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal RBCs.

yuyiding · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: The blood pressure has not had a significant rise.
Rationale 2: The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The assessment finding most abnormal and life-threatening is the urine output change.
Rationale 3: The reflexes are normal at 21.
Rationale 4: The platelet count is normal, though it is at the lower end.

Answer to Question 2

Correct Answer: 3
Rationale 1: In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected.
Rationale 2: Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type.
Rationale 3: In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected.
Rationale 4: The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal RBCs.