A client at 20 weeks gestation reports discomfort after amniocentesis procedure to the nurse. Which of the following assessment findings warrants priority action by the nurse?

Braxton Hicks contraction

Amniotic fluid contains fetal urine

Prolonged vaginal bleeding

Lab results reveal abnormal chromosome cells

Answer and Explanation

The Correct Answer is C

Explanation:

A. Braxton Hicks contraction

Braxton Hicks contractions are often referred to as "practice" contractions and are common during pregnancy. They are typically irregular and do not cause cervical changes. While discomfort after an amniocentesis procedure can sometimes trigger Braxton Hicks contractions, they are not usually a cause for immediate concern unless they become frequent, intense, or are accompanied by other signs of preterm labor, such as regular contractions, lower back pain, pelvic pressure, or changes in vaginal discharge.

B. Amniotic fluid contains fetal urine

The presence of fetal urine in the amniotic fluid is a normal and expected process during pregnancy. Fetal urine production contributes to the volume and composition of amniotic fluid, helping maintain the environment in the uterus and supporting fetal development. This finding is not directly related to the client's discomfort after an amniocentesis procedure and is not a cause for immediate concern unless there are other complications or abnormalities related to the amniotic fluid composition.

C. Prolonged vaginal bleeding

Prolonged vaginal bleeding after an amniocentesis procedure is a significant finding that requires immediate attention. While some spotting or mild bleeding can occur after the procedure, prolonged or significant bleeding may indicate complications such as uterine injury, placental abruption, or other issues that need urgent assessment and intervention by healthcare providers.

D. Lab results reveal abnormal chromosome cells

Abnormal chromosome cells found in the amniotic fluid sample obtained during amniocentesis may indicate genetic abnormalities or conditions in the fetus. While this finding is significant and requires follow-up and further evaluation, it is not an immediate concern in terms of the client's discomfort or the need for priority action by the nurse unless it is associated with other urgent clinical signs or symptoms.

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Correct Answer is D

Explanation

Explanation:

A. Bowel sounds

While assessing bowel sounds is important in general nursing care, it is not the priority assessment when administering magnesium sulfate IV to a client in preterm labor. Bowel sounds can provide information about gastrointestinal function and potential complications like bowel obstruction or ileus. However, these assessments are not directly related to the immediate effects of magnesium sulfate on the client or fetus during preterm labor.

B. Temperature

Monitoring temperature is important to detect signs of infection, which could be a concern in any patient receiving IV medications. However, it is not the priority assessment when administering magnesium sulfate IV for preterm labor. The primary concern with magnesium sulfate is its effect on neuromuscular function and its potential impact on the fetus, making fetal heart rate monitoring a higher priority.

C. Respiratory rate

Assessing respiratory rate is crucial for monitoring respiratory status and detecting signs of respiratory distress or magnesium toxicity, which can affect respiratory function. While respiratory rate is an essential assessment, it is not the priority when administering magnesium sulfate IV for preterm labor. Fetal heart rate monitoring takes precedence due to the direct impact of magnesium sulfate on uterine contractions and fetal well-being.

D. Fetal heart rate (FHR)

Fetal heart rate monitoring is the priority nursing assessment when preparing to administer magnesium sulfate IV to a client experiencing preterm labor. Magnesium sulfate can affect fetal heart rate and overall fetal well-being, so continuous fetal heart rate monitoring allows the nurse to assess the baby's response to the medication and detect any adverse effects promptly. Monitoring FHR helps ensure the safety and well-being of the fetus during magnesium sulfate therapy.

A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions

Correct Answer is C

Explanation

Explanation:

A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:

Fine tremors are a known side effect of terbutaline, which is often used to delay preterm labor by relaxing the uterus. While tremors are a common and expected side effect of terbutaline, they are not typically considered an urgent concern unless they are severe or accompanied by other concerning symptoms.

B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:

Proteinuria (2+) and increased deep tendon reflexes (2+) are significant findings in a client with preeclampsia, indicating worsening of the condition and potential organ involvement. However, they may not require immediate reporting unless accompanied by other severe symptoms such as severe hypertension, severe headache, visual disturbances, or epigastric pain.

C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:

This is the correct answer. Epigastric pain and unresolved headache are concerning symptoms in a client with preeclampsia and can indicate worsening of the condition or complications such as HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). These symptoms may suggest liver involvement, which is a serious complication of preeclampsia and requires immediate evaluation and management by the provider.

D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:

While tearfulness and irregular, frequent contractions may indicate emotional distress or early labor, they are not typically considered urgent findings unless accompanied by other signs of impending preterm labor such as cervical changes or regular, painful contractions. Immediate reporting is important if there are signs of active labor or cervical changes, but based on the information provided, this finding is not as urgent as the epigastric pain and unresolved headache in a client with preeclampsia.

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A client at 20 weeks gestation reports discomfort after amniocentesis procedure to the nurse. Which of the following assessment findings warrants priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is D

Explanation

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

Correct Answer is C

Explanation

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.)

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make?

A nurse is admitting a client who is at 37 weeks of gestation and diagnosed with severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was July 4, 2020. Which of the following is the appropriate response by the nurse?

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?