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

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.

A. Elevated WBC count. B. Fever. C. Ecchymosis. D. Fatigue.

Correct Answer is C

Explanation

Choice A rationale

While an elevated WBC count can indicate an infection, it is not the most important symptom to monitor in a patient with idiopathic thrombocytopenic purpura (ITP). ITP is primarily a platelet disorder, and while infection can trigger or exacerbate the condition, an elevated WBC count is not a direct symptom of ITP78.

Choice B rationale

Fever can be a sign of infection, which can trigger or exacerbate ITP. However, it is not the most important symptom to monitor in a patient with ITP78.

Choice C rationale

Ecchymosis, or bruising, is a key symptom of ITP. Because ITP involves a decrease in platelets, which are necessary for clotting, patients with this condition are prone to bruising and bleeding. Therefore, monitoring for ecchymosis is crucial.

Choice D rationale

Fatigue can be a symptom of ITP, but it is not the most important symptom to monitor. While fatigue can impact a patient’s quality of life, it does not directly indicate the severity of the condition.

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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 administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is developing a care plan for a patient who has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which of the following symptoms is most important for the nurse to monitor?

Correct Answer is C

Explanation

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