A nurse is caring for a group of patients on an intrapartum unit.
Which of the following findings should be reported to the healthcare provider immediately?
A patient at 28 weeks of gestation receiving terbutaline reports fine tremors.
A tearful patient at 32 weeks of gestation is experiencing irregular, frequent contractions.
A patient diagnosed with preeclampsia reports epigastric pain and an unresolved headache.
A patient diagnosed with preeclampsia has 2+ proteinuria and 2+ patellar reflexes.
The Correct Answer is C
Choice A rationale
A patient at 28 weeks of gestation receiving terbutaline may report fine tremors. This is a common side effect of terbutaline, which is a medication used to relax the muscles in the uterus to prevent premature labor. However, while it may be uncomfortable for the patient, it is not typically a cause for immediate concern.
Choice B rationale
A tearful patient at 32 weeks of gestation experiencing irregular, frequent contractions could be experiencing Braxton Hicks contractions, which are often referred to as “false labor.”. These contractions are usually irregular and do not increase in intensity or frequency. While they can be uncomfortable, they are a normal part of pregnancy and do not typically require immediate medical attention. Choice C rationale
A patient diagnosed with preeclampsia reporting epigastric pain and an unresolved headache should be reported to the healthcare provider immediately. These symptoms could indicate severe preeclampsia, which can lead to serious complications if not treated promptly. Epigastric pain may suggest liver involvement, and a persistent headache could be a sign of neurological involvement, both of which require immediate medical attention.
Choice D rationale
A patient diagnosed with preeclampsia having 2+ proteinuria and 2+ patellar reflexes is expected. Proteinuria is a common symptom of preeclampsia, and hyperreflexia can be a sign of increased neurological excitability, a common feature of preeclampsia. However, these findings alone do not typically require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The correct transcription of two tenths of a milligram is 0.2 mg. This format avoids any potential confusion that could lead to a medication error.
Choice B rationale
While 0.20 mg is technically correct, it is not the preferred format. The trailing zero after the decimal point is unnecessary and could potentially lead to confusion.
Choice C rationale
20 mg is not correct. This is 100 times the intended dose of two tenths of a milligram, and could lead to a serious medication error.
Choice D rationale
2 mg is not correct. This is 10 times the intended dose of two tenths of a milligram, and could lead to a medication error.
Correct Answer is D
Explanation
The correct answer is D. Slightly above the umbilicus. At 22 weeks of gestation, the fundus, or top of the uterus, is typically located slightly above the umbilicus.
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