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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most appropriate response because it reassures the client that the amount of lochia she passed is normal and expected after lying down for a long time. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It usually decreases in amount and changes in color over time, from red to pink to brown to yellow.
Choice B reason: This is an incorrect response because it implies that the client has a complication that requires further evaluation. Retained placental fragments can cause excessive bleeding, infection, and uterine atony. The nurse should not alarm the client with this possibility without evidence.
Choice C reason: This is an incorrect response because it contradicts the normal patern of lochia. The amount of lochia usually decreases during the postpartum period, not increases. If the client has an increase in lochia, it could indicate a problem such as infection, subinvolution, or hemorrhage.
Choice D reason: This is an incorrect response because it confuses the client with unrelated information. Urinary tract infections are not associated with increased lochia. They are caused by bacteria entering the urinary tract and can cause symptoms such as dysuria, frequency, urgency, and hematuria. The nurse should not suggest that the client has a urinary tract infection without evidence.
Correct Answer is B
Explanation
Choice A reason:
A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.
Choice B reason:
An ice pack can reduce inflammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.
Choice C reason:
A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.
Choice D reason:
A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.
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