A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

2+ pitting edema of the lower extremities

Increased hemoglobin

Blood pressure 158/54 mm Hg

Client report of upper right quadrant pain

Answer and Explanation

The Correct Answer is D

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

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Correct Answer is A

Explanation

Rationale:

A. Swelling of the lips: Swelling of the lips can be an early sign of anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis because it rapidly reduces airway swelling, improves breathing, and supports blood pressure by constricting blood vessels.

B. Nausea: While nausea may occur during an allergic reaction, it is not a primary life-threatening symptom addressed by epinephrine. Epinephrine targets cardiovascular and respiratory symptoms more directly, not gastrointestinal discomfort.

C. Hand tremors: Tremors are actually a potential side effect of epinephrine due to its stimulation of the sympathetic nervous system. The medication is not intended to treat tremors and may even cause or worsen them temporarily.

D. Hyperglycemia: Epinephrine can increase blood glucose levels as a side effect, but it is not prescribed to treat or manage hyperglycemia. Managing blood glucose is not part of the therapeutic purpose of this emergency medication.

A. Chromosomal abnormalities B. Placental circulation C. Rh incompatibility D. Fetal breathing movements

Correct Answer is A

Explanation

Rationale:

A. Chromosomal abnormalities: Amniocentesis involves analyzing amniotic fluid to detect genetic and chromosomal disorders such as Down syndrome, trisomy 18, and neural tube defects. It is typically performed between 15 and 20 weeks gestation for diagnostic accuracy during this stage of fetal development.

B. Placental circulation: Assessment of placental blood flow and circulation is usually done via Doppler ultrasound, not amniocentesis. Amniocentesis does not evaluate the vascular function or perfusion status of the placenta.

C. Rh incompatibility: While amniocentesis may reveal fetal anemia due to Rh sensitization in rare cases, it is not the primary test used for diagnosing Rh incompatibility. Blood antibody screening and Doppler assessment of the middle cerebral artery are preferred for Rh-related concerns.

D. Fetal breathing movements: Fetal breathing is assessed through a biophysical profile or real-time ultrasound, not via amniotic fluid sampling. Amniocentesis does not provide information about the fetus’s respiratory activity or movement patterns.

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A nurse is assisting in the care of a client who has preeclampsia. Which of the following findings should the nurse report to an RN immediately?

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