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

Answer and Explanation

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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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.

A. Headache that does not respond to analgesics B. Breast engorgement and tenderness C. Lochia rubra with small clots D. Perineal pain and swelling

Correct Answer is A

Explanation

Headache that does not respond to analgesics.This is a possible sign of postpartum pre-eclampsia, a rare condition that occurs when a woman has high blood pressure and excess protein in her urine soon after childbirth.Postpartum pre-eclampsia can cause seizures and other serious complications if not treated.

Choice B is wrong because breast engorgement and tenderness are normal symptoms of breastfeeding and do not indicate postpartum pre-eclampsia.

Choice C is wrong because lochia rubra with small clots is a normal discharge of blood and tissue from the uterus after delivery and does not indicate postpartum pre-eclampsia.

Choice D is wrong because perineal pain and swelling are common after vaginal delivery and do not indicate postpartum pre-eclampsia.

Normal ranges for blood pressure are below 120/80 mm Hg and for protein in urine are below 150 mg/day.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

Correct Answer is B

Explanation

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

Correct Answer is A

Explanation

A nurse is caring for a client who has a diagnosis of HELLP syndrome. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia. Which outcome would indicate that the therapy is successful?

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. Which of the following findings indicates a therapeutic response?

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

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?