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 ["C","D","E"]
Explanation
The correct answers are Choices C, D, and E.
Choice A rationale
Fetal neck translucency is not typically evaluated during a biophysical profile. It is usually assessed during a first trimester ultrasound to screen for chromosomal abnormalities.
Choice B rationale
Fetal gender is not typically evaluated during a biophysical profile. The focus of a biophysical profile is on assessing the health and well-being of the fetus.
Choice C rationale
Fetal motion is one of the aspects evaluated during a biophysical profile. It is assessed to determine the activity level of the fetus.
Choice D rationale
Fetal breathing is one of the aspects evaluated during a biophysical profile. It is assessed to determine the respiratory function of the fetus.
Choice E rationale
Amniotic fluid volume is one of the aspects evaluated during a biophysical profile. It is assessed to determine the amount of amniotic fluid surrounding the fetus.
Correct Answer is D
Explanation
Choice D rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are reliable signs of true labor. During true labor, contractions cause the cervix to thin and open to prepare for the passage of the baby. This is in contrast to Braxton Hicks contractions, or “false labor,” which are irregular and do not result in changes to the cervix.
Choice A rationale
The position of the presenting part can provide information about the progress of labor and the likely need for interventions, but it is not a definitive sign of labor.
Choice B rationale
Membrane rupture, or “water breaking,” can occur before or during labor. However, not all women experience a noticeable rupture of membranes, and sometimes the fluid can leak slowly, making it less noticeable.
Choice C rationale
A regular contraction pattern can be a sign of labor, but contractions can also occur in patterns during false labor. Therefore, contraction pattern alone is not a definitive sign of labor.
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