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

The correct answer is choice c. Heart rate 72/min.

Choice A rationale:

A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.

Choice B rationale:

A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.

Choice C rationale:

A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.

Choice D rationale:

A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).

A. Provide the client with a cool sitz bath. B. Administer methylergonovine 0.2 mg IM. C. Apply a moist, warm compress to the perineum. D. Apply povidone-iodine to the client's perineum after she voids.

Correct Answer is A

Explanation

The correct answer is choice a. Provide the client with a cool sitz bath.

Choice A rationale:

A cool sitz bath can help reduce swelling and provide pain relief for a client with a fourth-degree laceration of the perineum. Cooling the area can also help minimize inflammation and promote healing.

Choice B rationale:

Methylergonovine is typically used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of perineal lacerations.

Choice C rationale:

Applying a moist, warm compress to the perineum is not recommended immediately postpartum for a fourth-degree laceration, as it can increase swelling and discomfort. Cool treatments are preferred initially.

Choice D rationale:

Applying povidone-iodine to the perineum is not a standard practice for managing perineal lacerations. It can cause irritation and is not necessary for wound care in this context.

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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

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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