A nurse on a postpartum unit is caring for a client.

For each finding, click to specify if the finding is consistent with uterine atony or infection. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Rationale for correct choices

• Preeclampsia: The client is at 30 weeks gestation with new-onset hypertension, right upper quadrant pain, headache, nausea, and facial edema, which are hallmark signs of preeclampsia. Laboratory findings, including thrombocytopenia (platelet count 98,000/mm³), elevated liver enzymes (AST 38, ALT 40), elevated uric acid (8.5 mg/dL), and proteinuria, further support this diagnosis.

• Blood pressure: The client’s blood pressure readings are elevated (148/94 mm Hg initially, 156/96 mm Hg an hour later), which is a key diagnostic criterion for preeclampsia. Hypertension directly contributes to maternal and fetal risk, making blood pressure monitoring critical in risk assessment and management.

• Urinalysis: Proteinuria (25 mg/dL) on urinalysis confirms renal involvement, a defining feature of preeclampsia. Detecting protein in the urine alongside elevated blood pressure strengthens the diagnosis and guides the nurse to monitor for worsening renal function or progression to severe preeclampsia.

Rationale for incorrect choices

• Urinary tract infection: The client has a normal WBC count in urine (2/low power field) and no significant bacteriuria or pyuria. Abdominal pain and nausea are better explained by preeclampsia rather than a urinary tract infection.

• Hyperemesis gravidarum: Although the client reports nausea and vomiting, hyperemesis gravidarum typically presents in the first trimester and involves severe dehydration, weight loss greater than 5% of pre-pregnancy weight, and ketonuria. This client is 30 weeks gestation with minimal weight gain and no ketones detected, making hyperemesis unlikely.

• Fetal heart rate: The fetal heart rate is within normal limits (140/min) and does not indicate maternal or fetal pathology at this time. While fetal monitoring is important, it is not a primary indicator of preeclampsia.

• Fundal height: The fundal height is consistent with gestational age (29 cm at 30 weeks) and does not provide evidence of preeclampsia. It is useful for general fetal growth assessment but is not a key diagnostic criterion in this context.

• Pain assessment: While right upper quadrant pain is present, pain alone cannot confirm preeclampsia without supporting evidence from blood pressure and urinalysis. Pain assessment is supplementary rather than definitive for risk evaluation.

A. Transport the client to another area of the nursing unit: The first priority during a fire is rescue, ensuring the safety of any individuals in immediate danger. Removing the client from the room prevents exposure to smoke, heat, and flames.

B. Activate the facility's fire alarm system: After ensuring the client’s safety, the nurse must alert others and initiate the facility’s emergency response. Early notification facilitates rapid evacuation and mobilization of fire response teams.

C. Close all nearby windows and doors: Closing doors and windows helps contain the fire, limits oxygen supply to the flames, and reduces the spread of smoke and fire to other areas of the unit.

D. Use the unit's fire extinguisher to attempt to put out the fire: Once people are safe and the alarm is activated, the nurse may attempt to extinguish a small, controllable fire using the appropriate fire extinguisher, following the PASS technique (Pull, Aim, Squeeze, Sweep).