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
When a couple is found to be carriers of an autosomal-recessive disorder, one of the actions the nurse can take is to discuss options with the couple, including amniocentesis to determine if their fetus is affected. This procedure can provide definitive information about the genetic status of the fetus, allowing the couple to make informed decisions about the pregnancy.
Correct Answer is C
Explanation
Choice A rationale
A sweat test is used to diagnose cystic fibrosis, a genetic disorder that affects the lungs and digestive system. It is not used to diagnose pernicious anemia.
Choice B rationale
Haptoglobin is a protein produced by the liver that binds to hemoglobin in the blood to prevent it from being excreted through the kidneys. While it can be used to diagnose conditions that cause the destruction of red blood cells, it is not used to diagnose pernicious anemia.
Choice C rationale
The Schilling test is used to determine whether the body absorbs vitamin B12 normally, which is crucial for the diagnosis of pernicious anemia. Pernicious anemia is a condition where the body is unable to absorb vitamin B12 due to a lack of intrinsic factor, a protein made in the stomach.
Choice D rationale
Antinuclear antibodies (ANAs) are a type of autoantibody that can attack the body’s own tissues. While they can be present in various autoimmune diseases, they are not used to diagnose pernicious anemia.
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