A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

2+ pitting edema of the lower extremities

Increased hemoglobin

Blood pressure 158/54 mm Hg

Client report of upper right quadrant pain

Answer and Explanation

The Correct Answer is D

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

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Correct Answer is D

Explanation

Rationale:

A. "You can apply counterpressure to your back with each position change.": Counterpressure is commonly used during labor to relieve back pain caused by fetal positioning. It is not relevant for postoperative cesarean pain, which is abdominal.

B. "You should change positions as little as possible.": Limiting movement after surgery can increase the risk of complications such as pneumonia and venous thromboembolism. Frequent, supported movement is encouraged to promote recovery and circulation.

C. "You should use patterned-paced breathing when changing positions.": Patterned-paced breathing is typically used during labor for pain management. While breathing techniques may offer mild comfort, they do not provide adequate support for incisional pain during movement.

D. "You can splint the incision with a pillow when changing positions.": Splinting the incision with a pillow provides support to the abdominal muscles, helping reduce tension and pain during movement. This is a safe and effective nonpharmacological strategy for post-cesarean clients.

A. Examine the client's nail beds. B. Place the client in the supine position. C. Encourage client to perform deep breathing exercises. D. Prepare to administer oxygen via Venturi face mask. E. Add a humidifier to the oxygen device.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

• Examine the client's nail beds: Assessing nail beds for cyanosis provides visual clues of hypoxia. This is a noninvasive, rapid method to evaluate tissue perfusion and oxygenation. The client's saturations are borderline low despite increasing oxygen.

• Place the client in the supine position: The supine position can reduce lung expansion and worsen hypoxia, especially after sedation. Elevating the head of the bed promotes lung expansion and better diaphragmatic movement.

• Encourage client to perform deep breathing exercises: Deep breathing helps expand alveoli and improves oxygen exchange. It may reduce the need for higher oxygen delivery if the hypoxia is due to shallow respirations after sedation.

• Prepare to administer oxygen via Venturi face mask: The client's O₂ saturation is dropping despite nasal cannula at 5 L/min. A Venturi mask delivers a more precise and consistent oxygen concentration, making it appropriate here.

• Add a humidifier to the oxygen device: Humidification is generally needed for oxygen above 4 L/min over long durations. This client has only been on oxygen for a short time post-procedure, so humidification is not urgently required.

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A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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