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
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A) Increase the client's fluid intake:
While adequate hydration is important for a postpartum client, it is not the priority when the client is experiencing excessive bleeding. The immediate concern is to address the potential cause of the bleeding, which is often uterine atony.
B) Assist the client on a bedpan to urinate:
Assisting the client to urinate is important for assessing bladder function and preventing bladder distention, but it is not the priority when the client is experiencing excessive postpartum bleeding.
C) Prepare to administer oxytocic medication:
Administering oxytocic medication is an appropriate intervention for treating uterine atony, but the priority is to assess the client's uterine fundus first to confirm the cause of the bleeding before initiating any treatment.
D) Palpate the client's uterine fundus:
Palpating the client's uterine fundus is the priority nursing intervention in this situation. Saturating two perineal pads with blood in a 30-minute period indicates excessive postpartum bleeding, which could be due to uterine atony. Palpating the fundus will help determine if it is firm, which would indicate adequate uterine contraction. If the fundus is boggy or not well contracted, it suggests uterine atony, and the nurse should take immediate action, such as administering oxytocic medication, to prevent further bleeding.
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