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 A
Explanation
Choice A rationale
Vitamin K is used to reverse the effects of warfarin. Warfarin is an anticoagulant that works by inhibiting the synthesis of vitamin K-dependent clotting factors. When the INR is too high, indicating a high risk of bleeding, vitamin K can be administered to increase the production of clotting factors and reduce the risk.
Correct Answer is B
Explanation
Choice A rationale
Quickening is the sensation of fetal movement by the pregnant woman. It usually occurs between 16 and 20 weeks of gestation.
Choice B rationale
Hegar’s sign is a probable sign of pregnancy that is characterized by the compressibility and softening of the cervical isthmus, which is the portion of the cervix between the uterus and the vaginal portion of the cervix. This sign typically presents between the fourth and sixth week of pregnancy. Therefore, if the nurse identifies a probable sign indicating the softening of the lower uterine segment, it is likely that the nurse has observed Hegar’s sign.
Choice C rationale
Braxton Hicks contractions are intermittent uterine contractions that occur during pregnancy. They are not a sign of labor and do not lead to cervical dilation or effacement. Therefore, they would not indicate the softening of the lower uterine segment.
Choice D rationale
Ballottement is a technique of palpating a floating structure by bouncing it and feeling it rebound. In the context of pregnancy, it refers to the movement of the fetus when the uterus is tapped during a pelvic examination. This does not indicate the softening of the lower uterine segment.
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