A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?

Blood glucose 110 mg/dL.

Urine protein of 3+.

Hemoglobin 13 g/dL.

Deep tendon reflexes of 2+.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

A blood glucose level of 110 mg/dL is within the normal range for a non-pregnant individual. During pregnancy, the target range for blood glucose levels may vary, but 110 mg/dL does not typically raise concerns for preeclampsia.

Choice C rationale:

A haemoglobin level of 13 g/dL is within the normal range for a pregnant woman. While haemoglobin levels are important to monitor during pregnancy, this value alone does not indicate a significant concern related to preeclampsia.

Choice D rationale:

Deep tendon reflexes (DTR) of 2+ are within the normal range. Higher DTR levels may be concerning, but a 2+ rating is normal and does not raise immediate alarm for preeclampsia.

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Correct Answer is C

Explanation

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

A. Offer the newborn 30 mL (1 oz) of water between feedings. B. Allow the baby to feed at least every 3 hr. C. Feed the newborn 5 to 10 min per breast. D. Expect two to four wet diapers every 24 hr.

Correct Answer is B

No explanation

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A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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