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 A
Explanation
Choice A rationale
If the fundus is palpable to the right of the midline, it may indicate that the bladder is distended. A full bladder can displace the uterus to one side.
Choice B rationale
Frequent uterine contractions are not typically associated with bladder distention. These contractions are a normal part of the postpartum period as the uterus returns to its pre- pregnancy size.
Choice C rationale
Having less than 2.5 cm of rubra lochia on a perineal pad does not indicate bladder distention. This is a normal finding in the postpartum period.
Choice D rationale
An increased thirst is not typically associated with bladder distention. It is a common symptom in the postpartum period due to fluid shifts and breastfeeding.
Correct Answer is B
Explanation
Choice A rationale: Fundus at umbilicus is expected 4 hours postpartum, indicating normal uterine involution. No abnormal bleeding or uterine atony is implied, so it’s not a priority concern.
Choice B rationale: Deep tendon reflexes 4+ are hyperactive and signal increased neuromuscular irritability, placing the client at high risk for seizures due to preeclampsia. Immediate magnesium sulfate therapy may be required.
Choice C rationale: Saturated pad in 30 minutes suggests heavy lochia but is not yet classified as hemorrhage. Requires monitoring, but seizure risk from preeclampsia is more immediately life-threatening.
Choice D rationale: Approximated episiotomy edges indicate proper healing and no infection or dehiscence. This is a normal finding and does not require urgent intervention.
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