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 D

Explanation

A) The client is carrying more than one fetus:
This condition is known as polyzygotic multiples (e.g., twins, triplets) and is not the definition of polyhydramnios. Polyhydramnios refers specifically to the excessive accumulation of amniotic fluid in a singleton pregnancy.

B) There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid:
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid is associated with neural tube defects and other fetal abnormalities. However, this is not the definition of polyhydramnios.

C) The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor:
While polyhydramnios can sometimes be associated with fetal anomalies, growth restriction, or fetal distress during labor, it is not the primary definition of the condition. Polyhydramnios itself refers to the excessive accumulation of amniotic fluid, and its presence does not always indicate fetal anomalies or distress. However, these associations may require further evaluation and monitoring during pregnancy.

D) An excessive amount of amniotic fluid is present:
Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid around the fetus. This excess fluid can lead to complications during pregnancy and labor, including preterm labor, premature rupture of membranes, and postpartum hemorrhage. It can also be associated with maternal diabetes, fetal anomalies, or other underlying maternal or fetal conditions.

A. A contraction that lasts 4 min followed by a period of relaxation B. Contractions that last for 60 seconds each with a 3-min rest between contractions C. Contractions that last for 60 seconds each with a 4-min rest between contractions D. Contractions that last 45 seconds each with a 3-min rest between contractions

Correct Answer is B

Explanation

A. A contraction that lasts 4 min followed by a period of relaxation: This pattern is not typical and could indicate hypertonic uterine activity, which is not usual in labor. Contractions lasting 4 minutes are prolonged and not physiologically normal.

B. Contractions that last for 60 seconds each with a 3-min rest between contractions: This pattern is indicative of regular contractions in active labor. The contractions last for about 60 seconds each, which is within the normal range, and they occur approximately every 3 minutes, which is consistent with active labor.

C. Contractions that last for 60 seconds each with a 4-min rest between contractions: This pattern indicates a longer interval between contractions than typically seen in active labor. Labor usually progresses with contractions closer together.

D. Contractions that last 45 seconds each with a 3-min rest between contractions: While the rest time is correct, the duration of the contractions in this option is shorter than the typical duration of contractions during active labor.

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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

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Correct Answer is D

Explanation

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

Correct Answer is B

Explanation

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