A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin.
Which of the following findings should the nurse report to the provider immediately?
Contractions lasting 90 seconds and occurring every 2 minutes
Fetal heart rate baseline of 140/min with moderate variability
Cervical dilation of 4 cm and effacement of 50%
Epigastric pain and nausea
The Correct Answer is D
Epigastric pain and nausea. This is because epigastric pain and nausea are signs of severe preeclampsia that indicate liver involvement and possible hepatic rupture.
This is a medical emergency that requires immediate intervention to prevent maternal and fetal complications.
Choice A is wrong because contractions lasting 90 seconds and occurring every 2 minutes are normal during labor induction with oxytocin and do not indicate severe preeclampsia.
Choice B is wrong because fetal heart rate baseline of 140/min with moderate variability is a reassuring sign of fetal well-being and does not indicate severe preeclampsia.
Choice C is wrong because cervical dilation of 4 cm and effacement of 50% are normal findings during labor induction and do not indicate severe preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client will have to monitor her blood pressure at home for a month after delivery because preeclampsia can persist or develop for the first time after delivery.The client should seek medical care if she has signs of postpartum preeclampsia, such as severe headaches, vision changes, severe belly pain, nausea and vomiting.
Choice A is wrong because magnesium sulfate is an anticonvulsant medication that is given to prevent seizures in women with severe preeclampsia during labor and usually for 24 hours after delivery.
It is not needed for another week.
Choice C is wrong because breastfeeding is not contraindicated in women with preeclampsia.Breastfeeding may even lower the blood pressure and help with bonding.
Choice D is wrong because contraception is not related to preeclampsia.The client should discuss with her healthcare provider about the best contraceptive method for her based on her medical history and preferences.
Correct Answer is C
Explanation
This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.
The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.
Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.
Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.
Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.