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 ["D"]
Explanation
A blood pressure of 179/99 mm Hg in a pregnant client is a cause for concern and should be reported to the provider. This could be a sign of preeclampsia, a serious condition that can occur during pregnancy characterized by high blood pressure and damage to other organ systems, most often the liver and kidneys. The other vital signs (temperature, pulse rate, and respiratory rate) are within normal ranges for a pregnant woman.
Correct Answer is B
Explanation
Choice A rationale
A baseline BP of 140/85 mmHg is considered high, but a current BP of 129/80 mmHg is within the normal range. Therefore, this would not typically indicate a risk for pregnancy-induced hypertension.
Choice B rationale
A significant increase in blood pressure from a baseline of 110/70 mmHg to a current BP of 145/85 mmHg could indicate a risk for pregnancy-induced hypertension.
Choice C rationale
A slight increase in blood pressure from a baseline of 120/80 mmHg to a current BP of 126/85 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
Choice D rationale
An increase in blood pressure from a baseline of 110/60 mmHg to a current BP of 120/63 mmHg would not typically indicate a risk for pregnancy-induced hypertension.
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