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 A

Explanation

Rationale:

A. Case manager: Case managers coordinate resources and support services for clients, including assistance with financial concerns and access to programs that provide free or low-cost baby formula. They are the best resource to help the client navigate community aid and social services.

B. Primary care provider: While the primary care provider manages the client’s overall health, they are not typically responsible for connecting clients with financial assistance programs related to infant feeding.

C. Nutritionist: Nutritionists provide dietary advice and education but generally do not address financial barriers or resource allocation for obtaining formula.

D. Pediatric nurse practitioner: Pediatric nurse practitioners focus on the infant’s health and development and may provide feeding guidance, but addressing the client’s financial inability to pay for formula falls outside their primary role.

A. Encourage the client to increase fluid intake. B. Obtain the client's weight. C. Palpate the access site for a thrill D. Auscultate the access site for a bruit.

Correct Answer is B

Explanation

Rationale:

A. Encourage the client to increase fluid intake: Clients receiving continuous peritoneal dialysis may need to restrict fluids to prevent volume overload, depending on residual kidney function and dialysis efficiency. Encouraging increased intake without provider orders can be harmful.

B. Obtain the client's weight: Daily weight is a critical indicator of fluid balance and dialysis effectiveness. Monitoring weight helps determine if the dialysis is removing the appropriate amount of fluid and supports adjustments to the treatment plan.

C. Palpate the access site for a thrill: A thrill is a vibration felt over an arteriovenous fistula, which is used in hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a soft catheter in the abdomen and does not produce a thrill.

D. Auscultate the access site for a bruit: A bruit, a whooshing sound heard over a vascular access, is associated with AV fistulas used in hemodialysis. It is not relevant for peritoneal dialysis, which uses a catheter and does not involve high-pressure blood flow.

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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?

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Naxlex Comprehensive Predictor Exams

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