A nurse is caring for a 30-year-old female client, primiparous, who delivered vaginally 4 days ago, presenting to the emergency department.
The nurse reviews the client’s history and physical to determine the cause of the client’s symptoms. Highlight the information from the history and physical that requires further evaluation.
- Fatigue, new-onset headache, and right upper quadrant abdominal pain unrelieved by ibuprofen.
- Vomiting a small amount of yellow fluid.
- Weakness and seeing “flashing lights.”
- Home blood pressure reading of 154/100 mm Hg.
- Primiparous client induced at 41 weeks gestation with misoprostol and oxytocin.
Fatigue, new-onset headache, and right upper quadrant abdominal pain unrelieved by ibuprofen
Vomiting a small amount of yellow fluid
Weakness and seeing “flashing lights
Home blood pressure reading of 154/100 mm Hg
Primiparous client induced at 41 weeks gestation with misoprostol and oxytocin
The Correct Answer is ["A","B","C","D","E"]
Critical Findings That Warrant Immediate Attention
- Fatigue, new-onset headache, and right upper quadrant abdominal pain unrelieved by ibuprofen
- These are hallmark symptoms of postpartum preeclampsia and possibly HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). The pain location and headache severity are especially concerning.
- Vomiting a small amount of yellow fluid
- While not diagnostic on its own, vomiting in combination with headache and abdominal pain may signal systemic involvement and worsening condition.
- Weakness and seeing “flashing lights”
- Visual disturbances are classic signs of neurological involvement in preeclampsia and may precede seizures (eclampsia).
- Home blood pressure reading of 154/100 mm Hg
- This is hypertensive and exceeds the diagnostic threshold (≥140/90 mm Hg). It’s a red flag for postpartum preeclampsia, especially when paired with other symptoms.
Less Concerning but Still Noted
- Primiparous client induced at 41 weeks gestation with misoprostol and oxytocin
- While induction and primiparity are risk factors, they are not direct causes of her current symptoms. Still, they add context to her susceptibility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Morphine is an opioid analgesic, not a primary antihypertensive, although it can have a vasodilatory effect. Magnesium sulfate is a central nervous system depressant and vasodilator used to prevent seizures in preeclampsia, but it is the second substance listed and the question asks for the order.
Choice B rationale
Magnesium sulfate is the second substance listed, and the question asks for the substance to decrease blood pressure first. While magnesium sulfate is a vasodilator, its primary use in this context is seizure prophylaxis. Hydralazine is an antihypertensive, but it is listed as the second substance for seizure prevention.
Choice C rationale
Hydralazine is an antihypertensive and would decrease blood pressure, but lorazepam is a benzodiazepine used to treat active seizures, not prevent them. Magnesium sulfate is the agent of choice for seizure prophylaxis in preeclampsia.
Choice D rationale
Hydralazine is a direct-acting vasodilator that primarily relaxes arterial smooth muscle, leading to a decrease in peripheral vascular resistance and, consequently, a reduction in blood pressure. Magnesium sulfate is a central nervous system depressant that decreases neuromuscular excitability, thereby preventing seizures in conditions like preeclampsia.
Correct Answer is D
Explanation
Choice A rationale
Mixing infant formula with breast milk is not recommended because the mother is trying to increase her breast milk supply, and introducing formula can decrease the infant's demand for breast milk, which in turn reduces the mother's milk production. This approach also risks overfeeding the infant and does not address the underlying issue of insufficient supply.
Choice B rationale
Introducing baby food at 5 months is generally not recommended as a primary solution for insufficient breast milk. The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months. Early introduction of solids can displace breast milk intake, leading to reduced milk production and potentially interfering with the infant's nutritional needs and digestive development.
Choice C rationale
Follow-up or transitional formulas are typically designed for infants older than 1 year. The infant in this scenario is 5 months old and requires a formula specifically tailored to meet the nutritional needs of infants under 1 year of age. Providing an inappropriate formula can lead to nutritional imbalances and potential digestive issues for the infant.
Choice D rationale
A 5-month-old infant's primary source of nutrition should still be breast milk or formula. If the mother is having difficulty pumping enough milk, supplementing with an iron-rich formula is the most appropriate recommendation. This ensures the infant receives adequate nutrition, including essential iron, which is critical for growth and development at this age. This approach also helps prevent nutritional deficiencies while allowing the mother to continue breastfeeding.
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