A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?
A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful
A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria
A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
A client who has preeclampsia and reports epigastric pain and unresolved headache
The Correct Answer is D
Choice D reason: A client who has preeclampsia and reports epigastric pain and unresolved headache should be reported to the RN immediately, as these are signs of severe preeclampsia and impending eclampsia, which can lead to seizures, coma, and death. The client may need anticonvulsant medication, magnesium sulfate infusion, and delivery of the fetus.
Choice A reason: A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful may have preterm labor, which should be monitored and treated accordingly. However, this is not as urgent as choice D, as the contractions may subside with hydration, rest, or tocolytic medication.
Choice B reason: A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria may have mild preeclampsia, which should be managed with antihypertensive medication, bed rest, and fetal monitoring. However, this is not as urgent as choice D, as the reflexes and proteinuria are not indicative of severe preeclampsia or eclampsia.
Choice C reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors may have a common side effect of terbutaline, which is a beta-adrenergic agonist that relaxes uterine smooth muscle and inhibits contractions. However, this is not as urgent as choice D, as the tremors are usually transient and benign. The nurse should monitor the client's vital signs, blood glucose, and fetal heart rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Administer terbutaline if the fundus is boggy is incorrect, as this action is contraindicated for a client who has a boggy fundus. Terbutaline is a tocolytic agent that can relax uterine contractions and worsen uterine atony and hemorrhage. The nurse should administer oxytocin or other uterotonic agents as prescribed to stimulate uterine contraction and prevent bleeding.
Choice B reason: Observe the lochia during palpation of fundus is correct, as this action can provide information about the amount, color, consistency, and odor of lochia. Lochia is the vaginal discharge that occurs after birth, which consists of blood, mucus, and tissue. The nurse should observe the lochia during fundal palpation and report any abnormal findings, such as excessive bleeding, large clots, foul smell, or infection.
Choice C reason: Document fundal height is correct, as this action can provide information about the progress of uterine involution. The fundus is the upper part of the uterus that can be palpated through the abdomen after birth. The nurse should document the fundal height in relation to the umbilicus and note any changes over time.
Choice D reason: Massage a firm fundus is incorrect, as this action is not necessary for a client who has a firm fundus. A firm fundus indicates adequate uterine contraction and involution and prevents excessive bleeding. The nurse should massage a boggy or soft fundus until it becomes firm and midline.
Choice E reason: Determine whether the fundus is midline is correct, as this action can provide information about the position of the uterus and bladder. The fundus should be midline and not displaced to either side. A deviated fundus can indicate bladder distension, which can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
Correct Answer is B
Explanation
Choice A reason: Perform fundal massage is incorrect, as this action is not indicated for a client who has a firm and midline fundus. Fundal massage is used to stimulate uterine contraction and prevent hemorrhage in clients who have a boggy or deviated fundus.
Choice B reason: Assist the client to ambulate is correct, as this action can promote lochia drainage and prevent pooling of blood in the vagina. The nurse should encourage the client to ambulate early and frequently after birth, as long as there are no contraindications. The nurse should also monitor the client for signs of orthostatic hypotension and provide assistance as needed.
Choice C reason: Check for blood under the client's butock is incorrect, as this action is not necessary for a client who has a small amount of lochia rubra on the perineal pad. Lochia rubra is normal and expected in the first few days after birth, and it indicates that the placental site is healing. The nurse should check for blood under the butock only if there is suspicion of excessive bleeding or concealed hemorrhage.
Choice D reason: Increase the rate of the IV fluids is incorrect, as this action is not indicated for a client who has a small amount of lochia rubra on the perineal pad. Increasing the rate of IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
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