As a nurse caring for a group of clients on an intrapartum unit, which of the following findings should be immediately reported to the provider?
A client diagnosed with preeclampsia reports epigastric pain and unresolved headache
A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions
A client diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes
A client at 28 weeks of gestation receiving terbutaline reports fine tremors
The Correct Answer is A
Choice A rationale
A client diagnosed with preeclampsia reporting epigastric pain and unresolved headache is a serious concern. Epigastric pain could indicate severe liver involvement, and a persistent headache could be a sign of progressing neurological involvement, both of which are severe features of preeclampsia. These symptoms suggest the condition may be worsening to eclampsia, a life-threatening complication characterized by the onset of seizure activity or coma in a woman with preeclampsia. Immediate medical attention is necessary to prevent further complications.
Choice B rationale
A tearful client at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing preterm labor. However, emotional distress and contractions do not necessarily indicate a medical emergency. It’s important to monitor the situation, but it does not need to be immediately reported to the provider.
Choice C rationale
A client diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes are expected findings. Proteinuria is a common sign of preeclampsia, and hyperreflexia can occur due to increased neuromuscular irritability. While these should be monitored, they do not need to be immediately reported to the provider.
Choice D rationale
A client at 28 weeks of gestation receiving terbutaline reporting fine tremors is an expected side effect of the medication. Terbutaline, a beta-adrenergic agonist, can cause tremors by stimulating the nervous system. While it may be uncomfortable for the client, it is not a medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
The normal respiratory rate for a newborn is between 30 and 60 breaths per minute. Therefore, a respiratory rate of 48 breaths per minute is within the expected reference range for a newborn.
Correct Answer is C
Explanation
Choice A rationale
Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.
Choice B rationale
Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.
Choice C rationale
Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.
Choice D rationale
Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.
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