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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Expressions of excitement are typical during the dependent, taking-in phase, which lasts for the first 24 to 48 hr after delivery. The client may relive and review her labor and delivery experience, and may need reassurance and validation from others.
Choice B reason:
Lack of appetite is not an expected finding during the dependent, taking-in phase, as the client may have increased hunger and thirst after delivery. The nurse should encourage adequate nutrition and hydration to promote healing and lactation.
Choice C reason:
Eagerness to learn newborn care skills is more characteristic of the dependent-independent, taking-hold phase, which begins around the third day postpartum. During this phase, the client becomes more confident and interested in caring for herself and her newborn.
ChoiceD reason:
Focus on the family unit and its members is more characteristic of the interdependent, letting-go phase, which occurs after the first week postpartum. During this phase, the client redefines her role within the family and society, and integrates the newborn into her life.
Correct Answer is D
Explanation
Choice A reason:
Given too soon, epidural anesthesia can cause fetal depression is incorrect, as epidural anesthesia does not cross the placenta and does not affect the fetal status.
Choice B reason:
Given too soon, epidural anesthesia will delay rupture of fetal membranes is incorrect, as epidural anesthesia does not interfere with the rupture of membranes. The rupture of membranes depends on the cervical dilation and effacement, the position of the presenting part, and the strength of contractions.
Choice C reason:
Given too soon, epidural anesthesia can cause maternal hypertension is incorrect, as epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return. The nurse should monitor the client's blood pressure and administer fluids and vasopressors as needed.
Choice D reason:
Given too soon, epidural anesthesia can prolong labor is correct, as epidural anesthesia can decrease the strength and frequency of contractions and reduce the urge to push. The nurse should ensure that the client has a good labor patern before administering epidural anesthesia and monitor the progress of labor afterwards.
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