A. Report of headache: Severe preeclampsia is associated with neurologic symptoms due to cerebral edema and vasospasm. Clients commonly report persistent headaches, visual disturbances, and altered mental status.

B. Absence of clonus: Clonus is a hyperactive reflex response often seen in severe preeclampsia, indicating increased neuromuscular irritability and possible central nervous system involvement. The presence, rather than absence, of clonus is expected.

C. Tachycardia: Severe preeclampsia is more commonly associated with hypertension and bradycardia rather than tachycardia. However, tachycardia may be present if the client is in distress or has an underlying complication.

D. Polyuria: Severe preeclampsia typically causes oliguria (reduced urine output) due to impaired kidney function and decreased renal perfusion, not polyuria.

A. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors: Fine tremors are a common expected side effect of terbutaline, which is a beta-adrenergic agonist used to stop preterm labor. It is not an emergency but should be monitored.

B. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes: Proteinuria and 2+ reflexes are consistent with mild preeclampsia and do not necessarily indicate worsening or severe disease. However, monitoring is required to detect progression.

C. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache: Epigastric pain and a persistent headache suggest impending eclampsia or hepatic involvement (HELLP syndrome) and require immediate medical intervention to prevent seizures, stroke, or organ failure.

D. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions: Irregular contractions at 32 weeks may indicate Braxton Hicks contractions or preterm labor, but they do not necessarily require immediate provider notification unless they become regular and progressive.

A. Maternal heart rate: While the maternal heart rate is important, it is not directly related to interpreting FHR patterns. However, it is necessary to differentiate between the maternal and fetal heart rate on the monitor.

B. Gestational age: While gestational age affects fetal heart rate (younger fetuses tend to have higher baseline rates), it is not a direct component of FHR interpretation.

C. Uterine contractions: Uterine contractions are crucial in FHR interpretation because they influence perfusion to the fetus. Decelerations occurring with contractions may indicate fetal distress (e.g., late decelerations suggest uteroplacental insufficiency).

D. Presence of accelerations and decelerations: Accelerations and decelerations provide key information about fetal well-being. Accelerations indicate fetal well-being, while decelerations may signal hypoxia, cord compression, or uteroplacental insufficiency.

A. Urinary output 40 mL in 2 hr: Oliguria (urine output < 30 mL/hr) is a sign of magnesium toxicity, which can lead to respiratory depression, loss of reflexes, and cardiac arrest. The kidneys excrete magnesium, and impaired renal function increases toxicity risk. This finding requires immediate action.

B. Fetal heart rate 158/min: A fetal heart rate of 158 bpm is within the normal range (110-160 bpm) and is not a priority concern.

C. Reflexes +2: A +2 reflex response is normal. In magnesium toxicity, reflexes become diminished or absent (+1 or 0), indicating neuromuscular depression.

D. Respirations 16/min: While respiratory depression is a concern with magnesium sulfate, a respiratory rate of 16 breaths/min is within normal limits (12-20 bpm) and does not require immediate intervention. However, monitoring is still necessary.

A. Increase the rate of maintenance IV infusion. Increasing IV fluids may help improve placental perfusion, but it is not the first action. Repositioning the client takes priority to improve blood flow before considering IV adjustments.

B. Administer oxygen using a nonrebreather mask. Oxygen is beneficial in improving fetal oxygenation, but positioning the client laterally should be done first to optimize blood flow before oxygen administration.

C. Elevate the client’s legs. Elevating the legs may be helpful in cases of hypotension, but this scenario describes late decelerations, which are related to uteroplacental insufficiency.

D. Place the client in the lateral position. Late decelerations are caused by uteroplacental insufficiency, leading to fetal hypoxia. The first action is to reposition the client to the lateral position, which improves blood flow to the placenta and enhances fetal oxygenation.

A. 3+ protein in the urine: Severe proteinuria (≥2+ on dipstick) is a diagnostic criterion for preeclampsia. The presence of 3+ proteinuria is consistent with preeclampsia.

B. 1+ pitting sacral edema: Edema is common in preeclampsia, especially in dependent areas like the hands, face, and sacral region. This is not inconsistent with preeclampsia.

C. Blood pressure 148/98 mm Hg: Preeclampsia is defined as blood pressure ≥140/90 mm Hg after 20 weeks of gestation, with proteinuria or other signs of organ dysfunction. A BP of 148/98 mm Hg is consistent with preeclampsia.

D. Deep tendon reflexes of +1: Hyperreflexia (+3 or +4 reflexes) is a common finding in preeclampsia due to neuromuscular irritability. A +1 reflex response indicates diminished reflexes, which is not characteristic of preeclampsia.

A. Gradual decrease in FHR that mirrors uterine contractions. Early decelerations are caused by fetal head compression during contractions, leading to a gradual, uniform decrease in FHR that mirrors the contraction. This is a benign finding and does not require intervention.

B. Abrupt decrease in FHR with rapid recovery. This describes variable decelerations, which are caused by umbilical cord compression and require intervention.

C. Increase in FHR of at least 15 beats lasting at least 15 seconds. This describes accelerations, which are a reassuring sign of fetal well-being.

D. Decrease in FHR after the peak of uterine contractions. This describes late decelerations, which are associated with uteroplacental insufficiency and require intervention.

A. Brownish vaginal discharge: Bloody show (pink-tinged mucus) may indicate labor, but brownish discharge alone does not confirm labor. It may indicate old blood or cervical changes.

B. Amniotic fluid in the vaginal vault: The presence of amniotic fluid suggests rupture of membranes, but rupture alone does not confirm active labor unless accompanied by cervical changes.

C. Report of pain above the umbilicus: Labor contractions typically begin in the lower back and radiate to the lower abdomen, not above the umbilicus. Upper abdominal pain may suggest another issue, such as preeclampsia.

D. Cervical dilation: Cervical dilation is the only definitive sign that labor is occurring. True labor involves progressive cervical dilation and effacement due to regular contractions.

A. Excessive carbohydrate intake: Many vegetarian protein sources (e.g., legumes, whole grains, fruits) are also high in carbohydrates, making blood sugar control more challenging for clients with gestational diabetes.

B. Difficulty managing blood sugar levels: While managing blood sugar can be a challenge, the root cause is often excessive carbohydrate intake rather than inherent difficulty in regulation.

C. Limited protein sources: While vegetarian diets limit animal protein, many plant-based protein sources (e.g., tofu, lentils, nuts) are available, making this less of a concern.

D. Lack of essential vitamins and minerals: A well-balanced vegetarian diet can provide all essential nutrients with proper planning. However, vegetarians should monitor vitamin B12, iron, and omega-3 intake, but this is not the biggest challenge specific to gestational diabetes.

A. A client who is experiencing fetal death at 32 weeks of gestation: Tocolytic therapy delays preterm labor to improve fetal outcomes. If fetal death has already occurred, there is no benefit in delaying labor.

B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation: Braxton-Hicks contractions are false labor contractions that do not cause cervical changes. Tocolytics are not needed for false labor.

C. A client who is experiencing preterm labor at 26 weeks of gestation: Tocolytic therapy is appropriate for preterm labor before 34 weeks of gestation, especially in very preterm pregnancies (before 28 weeks) to allow for fetal lung maturation and steroid administration.

D. A client who has a post-term pregnancy at 42 weeks of gestation: Tocolytics are used to delay preterm labor, not to stop contractions in post-term pregnancies. A 42-week pregnancy requires induction of labor, not suppression.