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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "I should use a firm mattress in my baby's crib.": A firm mattress reduces the risk of sudden infant death syndrome (SIDS) and suffocation by providing a stable, flat surface for safe infant sleep. This is a key recommendation in safe sleep guidelines.
B. "I should set my hot water heater at 130 degrees Fahrenheit.": Setting the water heater at 130°F increases the risk of scald burns, especially for infants and young children. The recommended temperature to prevent burns is 120°F or lower.
C. “I should use a crib with side rails that drop": Drop-side cribs have been banned due to safety concerns, including risk of entrapment and suffocation. Using a crib with fixed side rails is safer and recommended.
D. "I should position my baby on their stomach to sleep during the day.": Placing infants on their stomach to sleep increases the risk of SIDS. The safest position for sleep is on the back, both during the day and night.
Correct Answer is B
Explanation
Rationale:
A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.
B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.
C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.
D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.