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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.
This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.
Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.
Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.
Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.
Correct Answer is A
Explanation
Hydralazine can causetachycardia(fast heart rate) as a common side effect.
This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.
Choice B is wrong because hydralazine does not causehyperglycemia(high blood sugar).
Hydralazine is not known to affect glucose metabolism or insulin secretion.
Choice C is wrong because hydralazine does not causehypokalemia(low potassium levels).
Hydralazine is not a diuretic and does not increase potassium excretion.
Choice D is wrong because hydralazine does not causeconstipation.Hydralazine can causediarrheaas a common side effect, but not constipation.
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