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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not typically the symptom that should be prioritized. While discomfort can indicate an active ulcer, it does not necessarily signify a complication.

Choice B rationale

Hematemesis, or vomiting blood, is a serious symptom that could indicate a bleeding ulcer, which is a medical emergency. Therefore, this symptom should be prioritized.

Choice C rationale

Dyspepsia, or indigestion, is a common symptom of peptic ulcer disease. However, it is not typically the symptom that should be prioritized as it does not necessarily indicate a serious complication.

Choice D rationale

Constipation is not typically associated with peptic ulcer disease and therefore should not be prioritized.

A. “This is a concern, but strabismus is easily treated with patching.”. B. “I will call your primary care provider to report your concerns.”. C. “I will take your baby to the nursery for further examination.”. D. “This occurs because newborns lack muscle control to regulate eye movement.”.

Correct Answer is D

Explanation

Choice A rationale

Strabismus, or crossed eyes, is a condition that typically requires treatment and is not normal in newborns. It involves a lack of coordination between the muscles that control eye movement, causing the eyes to point in different directions.

Choice B rationale

While it’s important to report concerns to the primary care provider, this statement does not directly address the mother’s concern about her newborn’s crossed eyes.

Choice C rationale

Taking the baby to the nursery for further examination may be necessary in some cases, but it does not provide the mother with immediate reassurance or information about her newborn’s condition.

Choice D rationale

Newborns often lack the muscle control necessary to regulate eye movement, which can cause their eyes to cross. This is a normal part of development and typically resolves on its own within the first few months of life.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient who has been diagnosed with peptic ulcer disease.Which symptom should the nurse prioritize?

Correct Answer is B

Explanation

A nurse is caring for a new mother who is concerned that her newborn’s eyes cross.Which of the following statements is a therapeutic response by the nurse?

Correct Answer is D

Explanation

A nurse is instructing a male patient on how to perform a testicular self-examination.Which piece of information should the nurse include in the teaching?

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