A nurse is caring for a group of patients on an intrapartum unit.
Which of the following findings should be reported to the healthcare provider immediately?

A patient at 28 weeks of gestation receiving terbutaline reports fine tremors.

A tearful patient at 32 weeks of gestation is experiencing irregular, frequent contractions.

A patient diagnosed with preeclampsia reports epigastric pain and an unresolved headache.

A patient diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes.

Answer and Explanation

The Correct Answer is C

Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.

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Correct Answer is A

Explanation

Choice A rationale

The client’s symptoms of elevated blood pressure, 3+ edema in the lower extremities, and 3+ proteinuria are indicative of preeclampsia. Preeclampsia is a complication of pregnancy that begins after 20 weeks of gestation in women whose blood pressure had previously been in the standard range. It is associated with high blood pressure and signs of damage to another organ system, often the liver and kidneys. In this case, the nurse should initiate seizure precautions and monitor the client’s neurological status and liver function studies. Seizure precautions are necessary because eclampsia, a severe form of preeclampsia, can lead to seizures. Monitoring neurological status can help detect changes in the client’s condition, and liver function studies can help assess the impact of preeclampsia on the liver.

Choice B rationale

While the client does have a history of chronic hypertension, the current symptoms suggest a condition more severe than chronic hypertension. Administering antihypertensive medication and monitoring blood pressure and heart rate would be appropriate actions for managing chronic hypertension, but they may not be sufficient to address the client’s current condition.

Choice C rationale

Gestational diabetes is a condition characterized by high blood sugar levels that develop during pregnancy in women who did not have diabetes before pregnancy. The client’s symptoms do not indicate gestational diabetes. While administering insulin and monitoring blood glucose levels and fetal heart rate would be appropriate actions for managing gestational diabetes, they do not address the client’s current symptoms.

Choice D rationale

Preterm labor refers to regular contractions of the uterus resulting in changes in the cervix that start before 37 weeks of pregnancy. The client’s symptoms do not suggest preterm labor. Administering tocolytics and monitoring contraction pattern and cervical dilation would be appropriate actions for managing preterm labor, but they do not address the client’s current symptoms.

A. 3 cm above the umbilicus. B. 3 cm below the umbilicus. C. Slightly below the umbilicus. D. Slightly above the umbilicus. E. Answer and explanation

Correct Answer is D

Explanation

The correct answer is D. Slightly above the umbilicus. At 22 weeks of gestation, the fundus, or top of the uterus, is typically located slightly above the umbilicus.

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A nurse is caring for a group of patients on an intrapartum unit. Which of the following findings should be reported to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

50 grams of Magnesium sulfate is added to 1L of Lactated Ringers. After giving an initial loading dose, the nurse is to infuse a maintenance dose of 2 gm/hr. What rate should the IV pump be set at?

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. Which of the following medications should the nurse anticipate a prescription from the provider for the client?

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A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. What would be an appropriate nursing action in this situation?

A nurse is caring for a client who is 39 weeks pregnant and in active labor. The nurse detects the fetal heart tones above the client’s umbilicus at the midline. Which of the following positions should the nurse suspect the fetus is in?

A nurse is attending to a client in active labor and observes late decelerations on the fetal monitor. What should be the nurse’s priority action?

In the context of diabetes incidence and classification, which statement should maternity nurses be aware of?

A nurse is attending to a first-time pregnant woman who is at term. She is experiencing contractions but is unsure if she is in labor. Which of the following should the nurse identify as a labor sign?

A nurse is caring for a group of patients on an intrapartum unit.
Which of the following findings should be reported to the healthcare provider immediately?