A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?
A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful
A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria
A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors
A client who has preeclampsia and reports epigastric pain and unresolved headache
The Correct Answer is D
Choice D reason: A client who has preeclampsia and reports epigastric pain and unresolved headache should be reported to the RN immediately, as these are signs of severe preeclampsia and impending eclampsia, which can lead to seizures, coma, and death. The client may need anticonvulsant medication, magnesium sulfate infusion, and delivery of the fetus.
Choice A reason: A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful may have preterm labor, which should be monitored and treated accordingly. However, this is not as urgent as choice D, as the contractions may subside with hydration, rest, or tocolytic medication.
Choice B reason: A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria may have mild preeclampsia, which should be managed with antihypertensive medication, bed rest, and fetal monitoring. However, this is not as urgent as choice D, as the reflexes and proteinuria are not indicative of severe preeclampsia or eclampsia.
Choice C reason: A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors may have a common side effect of terbutaline, which is a beta-adrenergic agonist that relaxes uterine smooth muscle and inhibits contractions. However, this is not as urgent as choice D, as the tremors are usually transient and benign. The nurse should monitor the client's vital signs, blood glucose, and fetal heart rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice B reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, effacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Choice C reason: The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical effacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.
Choice D reason: The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
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