Select the 4 assessment findings the nurse should report to the provider.
Headache for 2 days unrelieved by Tylenol.
Blurred vision and dizziness.
Swelling of feet.
2+ pitting edema of the lower extremities.
Deep tendon reflexes 3+, absent clonus.
Fetal heart tones 150/min.
Blood pressure of 180/99 mm Hg
Correct Answer : A,B,D,G
Choice A rationale: A headache that lasts for 2 days and is not relieved by Tylenol is a concerning symptom in a pregnant client. This could be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby. Severe headaches are a common symptom of preeclampsia and should be reported to the healthcare provider immediately.
Choice B rationale: Blurred vision and dizziness are also symptoms of preeclampsia. These symptoms occur as a result of changes in the blood vessels in the brain due to high blood pressure. The brain relies on a healthy blood supply to function properly, and any disruption to this can lead to symptoms such as blurred vision and dizziness. These symptoms should be reported to the healthcare provider immediately as they may indicate a need for immediate treatment or monitoring.
Choice C rationale: While swelling of the feet is common in pregnancy due to fluid retention and increased blood flow, it is not typically a symptom that needs to be reported to the healthcare provider unless it is accompanied by other symptoms of preeclampsia or other complications. Swelling in the face and hands is more concerning than swelling in the feet.
Choice D rationale: 2+ pitting edema of the lower extremities is a sign of fluid overload in the body, which can be a symptom of preeclampsia. This should be reported to the healthcare provider as it may indicate a need for treatment or closer monitoring.
Choice E rationale: Deep tendon reflexes of 3+ and absent clonus are within normal limits for a pregnant client. Hyperreflexia (reflexes rated as 4+) and the presence of clonus could indicate neurological irritability associated with preeclampsia, but these findings are not present in this client.
Choice F rationale: Fetal heart tones of 150/min are within the normal range of 110-160 beats per minute. This is a reassuring sign and does not need to be reported to the healthcare provider.
Choice G rationale: A blood pressure of 180/99 mm Hg is significantly elevated and is a hallmark sign of preeclampsia. This should be reported to the healthcare provider immediately as it indicates severe preeclampsia, which requires immediate treatment to prevent complications such as eclampsia, placental abruption, and organ damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it is important to monitor a client’s temperature regularly, especially if they have a fever, simply checking the client’s temperature in 4 hours is not an adequate response to a temperature of 38.9°C (102°F) in a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. This could indicate an infection, which could be dangerous for both the mother and the baby.
Choice B rationale
Administering glucocorticoids intramuscularly is not typically the first-line treatment for a fever in a pregnant woman. Glucocorticoids are often used to accelerate fetal lung maturity in preterm labor, but they are not typically used to treat infections or fevers.
Choice C rationale
Preparing the client for an emergency cesarean section may be necessary if the client’s condition worsens or if there are other complications, but it is not the immediate response to a fever. The first step would be to identify and treat the cause of the fever, which could be an infection.
Choice D rationale
Administering acetaminophen orally is an appropriate nursing action for a client with a fever. Acetaminophen can help to reduce the client’s fever and make her more comfortable. However, it is also important to identify and treat the underlying cause of the fever, which could be an infection.
Correct Answer is A
Explanation
Choice A rationale
Placing the client in a lateral position can help improve blood flow to the uterus and placenta, which can help stabilize the client’s blood pressure and the fetal heart rate.
Choice B rationale
Monitoring vital signs every 5 minutes is important, but the priority action is to address the client’s low blood pressure, which can compromise blood flow to the fetus.
Choice C rationale
Elevating the client’s legs can help increase venous return and improve blood pressure, but it is not the priority action in this situation.
Choice D rationale
Notifying the provider is important, but the nurse should first take action to stabilize the client’s condition.
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