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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vaginal discharge is common during pregnancy due to the increased production of estrogen and greater blood flow to the pelvic area. It is not typically a sign of preeclampsia.
Choice B rationale
Elevated blood pressure is a primary symptom of preeclampsia. If a pregnant client has high blood pressure, it should indicate to the nurse that the client requires further evaluation for this disorder.
Choice C rationale
Joint pain is not typically a symptom of preeclampsia. It could be related to other conditions or simply a result of the physical changes of pregnancy.
Choice D rationale
Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output could potentially be a sign of kidney problems related to preeclampsia.
Correct Answer is A
Explanation
Choice A rationale
Late decelerations in the Fetal Heart Rate (FHR) are a type of FHR pattern observed during labor, indicating a potential compromise of fetal well-being. They often begin just after a contraction, with their lowest point occurring after the peak of the contraction. These decelerations are associated with maternal and fetal conditions. Changing the client’s position can help alleviate the pressure on the fetus and improve blood flow, potentially reducing the occurrence of late decelerations. Therefore, the first action the nurse should take when noting late decelerations in the FHR is to change the client’s position.
Choice B rationale
Applying a fetal scalp electrode is a method used to monitor the FHR more accurately. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice C rationale
Administering oxygen can help increase the oxygen supply to the fetus. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
Choice D rationale
Increasing the rate of the IV infusion can help improve uteroplacental perfusion. However, it is not the first action to take when late decelerations are noted. The priority is to address the potential cause of the decelerations, such as changing the client’s position to improve blood flow.
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