A nurse is caring for a group of clients on an intrapartum unic. Which of the following findings should be reported to the provider immediately?

A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors

A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes

A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache

A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions

Answer and Explanation

The Correct Answer is C

C) A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache:
Epigastric pain and unresolved headache are signs of worsening preeclampsia, indicating possible impending eclampsia, a severe complication characterized by seizures. These symptoms suggest a significant deterioration in the client's condition and require immediate medical attention to prevent serious maternal and fetal complications.

A) A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors:
Fine tremors are a common side effect of terbutaline, which is often used to suppress preterm labor. While tremors can be uncomfortable for the client, they are not typically life-threatening and can often be managed without immediate medical intervention.

B) A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes:
While proteinuria and increased reflexes are indicative of preeclampsia, they are not immediate concerns unless other severe symptoms are present. However, the combination of epigastric pain and unresolved headache in a client with preeclampsia indicates a worsening condition that requires urgent medical attention.

D) A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions:
While tearfulness and irregular, frequent contractions should be assessed, they are not typically indicators of an immediately life-threatening condition. In this scenario, the client's symptoms of epigastric pain and unresolved headache are more concerning and require immediate reporting to the healthcare provider.

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Correct Answer is D

Explanation

A) "This is erythema toxicum, which is a transient condition": Erythema toxicum is a benign and common rash in newborns characterized by red, blotchy areas with white or yellow papules or vesicles in the center. It is not associated with swelling on the head and does not cross suture lines.

B) "Mongolian spots can be found on the skin of many newborns": Mongolian spots are areas of blue or purple pigmentation on the skin, typically found on the lower back or buttocks. They are unrelated to swelling on the head and do not cross suture lines.

C) "This is a cephalhematoma, which can occur spontaneously": This statement is incorrect. A cephalhematoma is a collection of blood between a skull bone and its periosteum and is caused by trauma during birth, such as the use of vacuum extraction or forceps. It is confined by suture lines and does not cross them. Therefore, this response is inaccurate.

D) "A caput succedaneum occurs due to compression of blood vessels": A caput succedaneum is swelling that occurs due to pressure exerted on the fetal head during labor or delivery. It typically appears as soft tissue swelling and crosses suture lines. This response accurately describes the condition presented by the newborn and provides the mother with appropriate information.

A. The posterior fontanel is palpable. B. The lowermost portion of the fetus is at the level of the ischial spines. C. The fetal head is in the left occiput posterior position. D. The largest fetal diameter has passed through the pelvic outlet.

Correct Answer is B

Explanation

A) The posterior fontanel is palpable:
This statement is not directly related to station. The fontanelles are soft spots on the fetal skull used to assess fetal head position, but they are not specifically related to station.

B) The lowermost portion of the fetus is at the level of the ischial spines:
In obstetrics, station refers to the relationship between the presenting part of the fetus and the maternal ischial spines. When the presenting part is at 0 station, it means that the lowest part of the fetus (usually the head) is at the level of the maternal ischial spines. This is a significant landmark indicating the progress of labor. As labor progresses, the fetus descends further into the pelvis, with stations progressing from -3 to +3.

C) The fetal head is in the left occiput posterior position:
The station does not provide information about the fetal head position. Left occiput posterior position refers to the position of the fetal head in relation to the maternal pelvis, which is determined separately through pelvic examinations.

D) The largest fetal diameter has passed through the pelvic outlet:
While 0 station indicates engagement of the fetal head in the pelvis, it does not necessarily mean that the largest fetal diameter has passed through the pelvic outlet. Labor continues until the entire fetus is delivered through the birth canal, which occurs as labor progresses through the different stages.

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A nurse is caring for a group of clients on an intrapartum unic. Which of the following findings should be reported to the provider immediately?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct Interpretation of this clinical finding?

Correct Answer is B

Explanation

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