A nurse is caring for a group of clients on an intrapartum unic. Which of the following findings should be reported to the provider immediately?
A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes
A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache
A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions
The Correct Answer is C
C) A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
Epigastric pain and unresolved headache are signs of worsening preeclampsia, indicating possible impending eclampsia, a severe complication characterized by seizures. These symptoms suggest a significant deterioration in the client's condition and require immediate medical attention to prevent serious maternal and fetal complications.
A) A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors are a common side effect of terbutaline, which is often used to suppress preterm labor. While tremors can be uncomfortable for the client, they are not typically life-threatening and can often be managed without immediate medical intervention.
B) A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
While proteinuria and increased reflexes are indicative of preeclampsia, they are not immediate concerns unless other severe symptoms are present. However, the combination of epigastric pain and unresolved headache in a client with preeclampsia indicates a worsening condition that requires urgent medical attention.
D) A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
While tearfulness and irregular, frequent contractions should be assessed, they are not typically indicators of an immediately life-threatening condition. In this scenario, the client's symptoms of epigastric pain and unresolved headache are more concerning and require immediate reporting to the healthcare provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pattern of contractions: While the pattern of contractions is an essential aspect of labor, it alone does not confirm whether the client is experiencing true labor. True labor contractions are typically regular, become stronger over time, and occur at shorter intervals.
B. Rupture of the membranes: Rupture of membranes, also known as the water breaking, can occur in both true and false labor. However, it is not the defining factor in distinguishing true labor.
C. Changes in the cervix: Changes in the cervix, such as cervical dilation and effacement, are indicative of true labor. Cervical dilation and effacement occur progressively during true labor, suggesting that the body is preparing for the birth of the baby.
D. Station of the presenting part: The station of the presenting part refers to the level of the fetal head in the pelvis and is an important aspect of labor progress. However, it alone does not confirm whether the client is experiencing true labor.
Correct Answer is B
Explanation
A) Nausea: Nausea is a common side effect of magnesium sulfate therapy but is not necessarily indicative of magnesium sulfate toxicity. It is important to monitor for nausea, but it is not the most critical finding to indicate toxicity.
B) Respiratory depression: Respiratory depression is a severe sign of magnesium sulfate toxicity and should be reported to the provider immediately. Magnesium sulfate can depress the central nervous system, leading to respiratory depression, which is a potentially life-threatening complication.
C) Drowsiness: Drowsiness is a common side effect of magnesium sulfate therapy, especially at therapeutic levels. However, it is not necessarily indicative of magnesium sulfate toxicity. While drowsiness should be monitored, it is not as critical as respiratory depression in indicating toxicity.
D) Facial flushing: Facial flushing is a common side effect of magnesium sulfate therapy and is not typically associated with magnesium sulfate toxicity. While it can be uncomfortable for the patient, it is not a severe indication of toxicity compared to respiratory depression.
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