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

Answer and Explanation

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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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.

A. Inform the client the anesthetic effect will last for approximately 6 hr. B. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. C. Administer a 500 mL bolus of 5% dextrose in water prior to induction. D. Have the client stand at the bedside with her arms at her side.

Correct Answer is B

Explanation

A) Inform the client the anesthetic effect will last for approximately 6 hr:
This statement is inaccurate. While the duration of the analgesic effect may vary, epidural analgesia typically provides pain relief for the duration of labor. It is not appropriate to provide a specific time frame like 6 hours as the duration can vary widely depending on the type of medication used and individual response.

B) Obtain a 30-min electronic fetal monitoring (EFM) strip prior to induction:
This is the correct action. It is essential to obtain a baseline fetal heart rate tracing for at least 20-30 minutes prior to initiating epidural analgesia. This allows the healthcare team to assess the fetal status and identify any baseline abnormalities before the initiation of anesthesia.

C) Administer a 500 mL bolus of 5% dextrose in water prior to induction:
This action is not directly related to the preparation for epidural analgesia. Providing a dextrose solution is not a standard practice before epidural placement.

D) Have the client stand at the bedside with her arms at her side:
This action is not appropriate for preparing a client for epidural analgesia. The client should be in a comfortable position, such as sitting or lying on the side, for the procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Correct Answer is B

Explanation

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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 nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct Interpretation of this clinical finding?

A nurse is completing an 8-hr 1&O record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?