A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol.
For which of the following findings should the nurse withhold the medication?

Uric acid 7.5 mg/dL (2.7 to 7.3 mg/dL).

Heart rate 54/min.

FHR 112/min.

BUN 23 mg/dL (10 to 20 mg/dL).

Answer and Explanation

The Correct Answer is B

Choice A rationale

Uric acid levels in preeclampsia can be elevated due to decreased renal clearance and increased production, often exceeding the normal range of 2.7 to 7.3 mg/dL. A value of 7.5 mg/dL is slightly elevated, which is a common finding in preeclampsia and does not typically contraindicate the administration of labetalol, an antihypertensive medication. It reflects disease progression but does not pose an immediate risk regarding medication administration.

Choice B rationale

Labetalol is a beta-blocker that reduces heart rate and blood pressure. A heart rate of 54/min is below the normal adult resting heart rate range (typically 60-100 beats/min) and indicates bradycardia. Administering labetalol to a client with pre-existing bradycardia could further depress the heart rate, potentially leading to symptomatic bradycardia, decreased cardiac output, and inadequate tissue perfusion, thus requiring the nurse to withhold the medication.

Choice C rationale

A fetal heart rate (FHR) of 112/min is within the normal range for a fetus (typically 110-160 beats/min). While labetalol can rarely cause fetal bradycardia, a baseline FHR of 112/min does not contraindicate its administration. The primary concern with labetalol in preeclampsia is the maternal hemodynamic response, and this FHR value does not indicate an immediate fetal distress that would preclude the medication.

Choice D rationale

A BUN level of 23 mg/dL is slightly elevated above the normal range of 10 to 20 mg/dL, often seen in preeclampsia due to impaired renal function. While this indicates renal involvement, it does not contraindicate the administration of labetalol. Labetalol is primarily metabolized by the liver, and while caution is advised in renal impairment, this BUN level alone does not warrant withholding the medication.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should first monitor the client’s fundal tone followed by the client’s heart rate.

Rationale for correct answers
Fundal tone is the primary indicator of uterine contractility. A boggy fundus that does not firm with massage indicates uterine atony, the most common cause of postpartum hemorrhage (PPH). Effective uterine contraction compresses uterine blood vessels to reduce bleeding. Monitoring fundal tone allows early identification of hemorrhage risk. Heart rate is a sensitive early sign of hypovolemia; a rising heart rate (tachycardia above 100 beats/min) reflects compensatory response to blood loss before blood pressure drops. Normal adult heart rate ranges from 60 to 100 beats/min; an increase indicates circulatory stress.

Rationale for incorrect answers
Bruising to perineal area (A) is important but secondary; it does not directly assess bleeding severity or uterine status. Pain level (C) is subjective and can be influenced by many factors; it does not reliably indicate hemorrhage. Uterine height (D) measures fundal location but does not assess firmness or tone, which are critical for detecting atony. Temperature (B) changes are not immediate indicators of bleeding. Pain level (C) and uterine height (D) similarly lack specificity for hemorrhage assessment compared to fundal tone and heart rate.

Take home points

Fundal tone assessment is critical for early detection of uterine atony causing postpartum hemorrhage.
Tachycardia is an early physiological sign of hypovolemia and should be closely monitored.
Perineal bruising and pain are secondary findings and less specific to hemorrhage severity.
Uterine height and temperature changes do not reliably indicate acute hemorrhage status.

A. Shrill cry. B. Weak peripheral pulses. C. Yellowish skin. D. Hypotonia.

Correct Answer is A

Explanation

Choice A rationale

A shrill or high-pitched cry in a newborn can be a symptom of neurological irritability, which is often associated with hypoglycemia. Hypoglycemia in newborns can lead to central nervous system dysfunction due to insufficient glucose supply to the brain, manifesting as altered cry patterns.

Choice B rationale

Weak peripheral pulses can indicate poor cardiac output or peripheral vasoconstriction, which might be associated with conditions like congenital heart defects or hypovolemia. While significant hypoglycemia can impact cardiovascular function, weak pulses are not the primary or most specific indicator.

Choice C rationale

Yellowish skin, or jaundice, is caused by elevated bilirubin levels in the blood, often due to physiological immaturity of the liver or increased red blood cell breakdown. While jaundice can be a symptom of various newborn issues, it is not a direct or common sign of hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a symptom of various neurological issues, including severe hypoglycemia, but also other conditions like birth trauma, sepsis, or genetic disorders. While it can be present with hypoglycemia, a shrill cry is a more specific and earlier indicator.

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A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who is in the fourth stage of labor in the postpartum unit. Complete the following sentence by using the list of options. The nurse should first monitor the client’s ________ followed by the client’s __________.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

Correct Answer is A

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A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol.
For which of the following findings should the nurse withhold the medication?