A nurse is caring for a female client, age 30, at 37 weeks of gestation, admitted to the labor and delivery unit from the provider’s office for observation and laboratory testing.
Which of the following assessment findings should the nurse report to the provider?
Moderate fetal heart rate variability
Headache
Heart rate
Edema
Blood pressure
Fetal heart rate
Irregular contractions
Negative ankle clonus
Patellar deep tendon reflexes
Correct Answer : B,D,E
Choice A rationale: Moderate fetal heart rate variability indicates a healthy autonomic nervous system response in the fetus, reflecting adequate oxygenation and neurologic function. Variability within moderate range (6-25 beats/min) suggests the fetus is not currently experiencing hypoxia or acidosis. This finding is reassuring and does not require urgent reporting as it reflects normal fetal well-being according to obstetrical monitoring standards.
Choice B rationale: Persistent headache unrelieved by acetaminophen in a pregnant client with elevated blood pressure is a significant symptom suggestive of worsening preeclampsia or impending eclampsia. Headache can result from cerebral vasospasm or edema and requires prompt evaluation as it indicates central nervous system involvement. Elevated blood pressure over 140/90 mm Hg plus headache raises concern for severe preeclampsia.
Choice C rationale: The heart rate of 98 beats/min is within normal adult range (60-100 bpm) and is not clinically concerning in this context.
Choice D rationale: Edema, especially 2+ pitting in the lower extremities and hands, is common in pregnancy but circumorbital and hand edema preventing ring removal is concerning. It may indicate fluid retention due to endothelial dysfunction and capillary leakage seen in preeclampsia. Such edema suggests worsening vascular permeability and should be reported for timely management.
Choice E rationale: Blood pressure reading of 160/98 mm Hg is above the normal pregnancy threshold (less than 140/90 mm Hg) and qualifies as severe hypertension. Elevated blood pressure is a key diagnostic criterion for preeclampsia and increases risk for maternal and fetal complications including stroke, placental abruption, and fetal growth restriction, requiring immediate provider notification.
Choice F rationale: The fetal heart rate of 130 beats/min falls within the normal baseline range (110-160 bpm) with moderate variability, indicating no current fetal distress. This normal finding does not require urgent reporting as it reflects appropriate fetal status.
Choice G rationale: Irregular contractions without pattern or intensity are common and often represent Braxton Hicks contractions, especially near term. These do not typically indicate active labor or distress and do not require urgent reporting unless they become regular, painful, or accompanied by other concerning symptoms.
Choice H rationale: Negative ankle clonus reflects normal neurological function and absence of central nervous system hyperreflexia. Presence of clonus could suggest severe preeclampsia with neurological involvement; its absence is reassuring and not a reportable concern.
Choice I rationale: Patellar deep tendon reflexes at 2+ are normal on a scale of 0 to 4+. Hyperreflexia (3+ or 4+) could indicate neurologic irritability from preeclampsia. Normal reflexes suggest no current severe neurological involvement, so this does not warrant immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.
Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.
Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.
Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.
Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via nasal cannula at 2 L/min might marginally increase fetal oxygenation, but it does not address the primary issue of hypotension causing decreased placental perfusion. The fundamental problem is reduced blood flow to the placenta, necessitating interventions that increase maternal circulating volume and blood pressure to improve perfusion.
Choice B rationale
Administering a lactated Ringer's 500 mL bolus directly addresses hypotension by expanding the maternal intravascular volume. This increased circulating volume raises blood pressure, thereby improving placental perfusion and oxygen delivery to the fetus. Lactated Ringer's is an isotonic solution, effective for rapid volume expansion.
Choice C rationale
Placing the client in a knee-chest position is typically used to alleviate cord compression or prolapse by shifting the fetus, not for treating hypotension. This position can actually worsen hypotension by trapping blood in the lower extremities and reducing venous return to the heart, further compromising placental blood flow.
Choice D rationale
Monitoring the client's blood pressure every 30 minutes is a crucial assessment but is not an immediate intervention for acute hypotension with decreased placental perfusion. While ongoing monitoring is essential, immediate actions are required to correct the underlying cause of hypotension and restore adequate blood flow to the placenta.
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