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 D

Explanation

Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.

A. One artery and one vein. B. Two veins and one artery. C. Two arteries and two veins. D. Two arteries and one vein.

Correct Answer is D

Explanation

Choice A rationale
The umbilical cord typically contains two arteries and one vein, not one artery and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice B rationale
The umbilical cord typically contains two arteries and one vein, not two veins and one artery. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice C rationale
The umbilical cord typically contains two arteries and one vein, not two arteries and two veins. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice D rationale
The umbilical cord typically contains two arteries and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.

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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

A nurse is monitoring a patient who is receiving magnesium sulfate to manage pre-eclampsia. Which of the following observations should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

A nurse in labor and delivery is caring for a client. Following the delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

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?

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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?