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Select the 4 assessment findings the nurse should report to the provider.

Exhibits
A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits:

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choiceC. Respiratory rate.

Choice A rationale:

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.

Choice B rationale:

While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.

Choice C rationale:

Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.

Choice D rationale:

Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.

A. Frequent urination B. Low back pain C. Temperature of 38.3°C (101°F) D. Strong urge to push E. Contractions every 1.5 minutes F. Pain level of 8 on a scale of 0 to 10

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

• Frequent urination: This is more likely to be associated with a UTI, as frequent urination is a common symptom of UTIs.
• Low back pain: This can be associated with both preterm labor and a UTI. Low back pain can be a sign of labor, and it can also be a symptom of a UTI.
• Temperature of 38.3°C (101°F): This is more likely to be associated with a UTI, as fever is a common symptom of infections, including UTIs.
• Strong urge to push: This is more likely to be associated with preterm labor, as an urge to push can be a sign of labor.
• Contractions every 1.5 minutes: This is more likely to be associated with preterm labor, as frequent contractions are a sign of labor.
• Pain level of 8 on a scale of 0 to 10: This can be associated with both preterm labor and a UTI. Severe pain can be a sign of labor, and it can also be a symptom of a UTI. Please note that these are potential associations and the healthcare provider should be informed immediately for further evaluation and management. It’s important to continue following the provider’s prescriptions and closely monitor the client’s condition.

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Select the 4 assessment findings the nurse should report to the provider. Exhibits A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits:

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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Select the 4 assessment findings the nurse should report to the provider.

Exhibits
A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits: