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 C

Explanation

Rationale:

A. "I will wait 1 hour after getting up in the morning to have breakfast.": Delaying breakfast may worsen nausea, as symptoms of hyperemesis gravidarum are often worse in the morning. It is recommended to eat a small, dry carbohydrate-rich snack, such as crackers, soon after waking.

B. "I will try to eat balanced meals instead of only foods that appeal to my taste.": While balanced meals are ideal, during hyperemesis gravidarum, the priority is tolerating any nutrition. Clients are encouraged to eat whatever foods they can tolerate, as nutritional intake is often severely limited.

C. “I will eat or drink something every 2 to 3 hours throughout the day": Eating or drinking small amounts frequently helps prevent an empty stomach, which can trigger or worsen nausea and vomiting. This approach improves tolerance and supports hydration and nutrition.

D. “I will eat a low protein snack 30 minutes before going to bed each night.": Protein-rich snacks, not low-protein ones, are better for stabilizing blood glucose levels overnight and may help reduce morning nausea. A high-protein snack before bed is more appropriate.

A. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report. B. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care. C. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for. D. A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use.

Correct Answer is B

Explanation

Rationale:

A. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is an appropriate and necessary exchange of client information for continuity of care. It supports safe, effective handoff communication between nurses involved in the client’s treatment.

B. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: This violates the Health Insurance Portability and Accountability Act (HIPAA) by sharing protected health information with someone not directly involved in the client’s care, regardless of location or setting.

C. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is an expected and proper part of nursing responsibilities. Accurate and timely documentation in the EMR is essential for effective communication and patient safety.

D. A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable health information is included, printing such materials for professional reference or education is acceptable and does not violate confidentiality rules.

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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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