A nurse is caring for a group of clients on a postpartum unit.
Which of the following findings should be reported to the RN immediately?
A client who has preeclampsia has 2+ patellar reflex and 2+ proteinuria
A client who is at 24 weeks of gestation
A client who has preeclampsia
A client who has a heart rate of 100/min
The Correct Answer is A
Choice A rationale:
2+ patellar reflex: A hyperactive patellar reflex (also known as a knee-jerk reflex) is a sign of hyperreflexia, which can be a neurological symptom of preeclampsia. Hyperreflexia results from heightened nerve excitability and can manifest as exaggerated reflexes. In preeclampsia, it stems from central nervous system irritability due to cerebral edema or other neurological disturbances.
2+ proteinuria: Proteinuria, defined as the presence of excessive protein in the urine, is a hallmark sign of preeclampsia. It indicates glomerular damage in the kidneys, leading to protein leakage into the urine. The degree of proteinuria is graded on a scale of 1+ to 4+, with 2+ representing a significant level that warrants immediate attention.
Choice B rationale:
24 weeks of gestation: While 24 weeks of gestation is considered early preterm birth, it is not inherently a finding that requires immediate reporting to the RN in the context of postpartum care. The focus on the postpartum unit is primarily on the health of the mother and newborn after delivery, rather than managing ongoing pregnancies.
Choice C rationale:
Preeclampsia: While preeclampsia is a serious condition that necessitates close monitoring and management, the mere diagnosis of preeclampsia without additional concerning findings does not automatically require immediate reporting to the RN. It's essential to assess for specific signs and symptoms that indicate worsening or complications of preeclampsia, such as those mentioned in Choice A.
Choice D rationale:
Heart rate of 100/min: A heart rate of 100 beats per minute is within the normal range for adults, even postpartum. Mild tachycardia (increased heart rate) can be a physiological response to various factors such as pain, anxiety, or exertion, and it does not always signify a serious problem. However, if the heart rate is persistently elevated or accompanied by other concerning symptoms, it would warrant further evaluation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The fundus at the umbilicus level is a normal finding in the immediate postpartum period. After delivery, the top of the uterus
(known as the fundus) is typically at the level of the umbilicus. In the days following delivery, the uterus begins to shrink and
descend into the pelvic cavity, guided by the process known as involution.
Choice B rationale:
A urinary output of 3,000 mL is unusually high and could indicate a postpartum complication. Postpartum diuresis is common
as the body eliminates excess fluid accumulated during pregnancy. However, excessive urinary output could be a sign of
postpartum complications such as postpartum preeclampsia, which can occur after the birth of the baby and is characterized
by high blood pressure and signs of damage to another organ system, often the kidneys.
Choice C rationale:
A temperature of 100.4 F for two days postpartum can be a normal finding. It’s not uncommon for women to experience a
slight elevation in temperature in the first 24 hours after delivery due to the exertion of labor. However, a temperature above100.4 F beyond the first 24 hours could indicate an infection and should be evaluated.
Choice D rationale:
A cesarean section shortly following delivery is not typically a sign of a postpartum complication. It’s a surgical procedure used to deliver the baby and can be planned or unplanned due to various reasons such as the baby’s position, multiple pregnancies, or complications during labor. However, like any surgery, a cesarean section does carry risks and can increase the likelihood of certain postpartum complications such as infection or blood clots.
Correct Answer is C
Explanation
The correct answer is choice c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.
Choice A rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages.
Choice B rationale:
This choice correctly states the cervix is dilated 3 cm and effaced 30%, but it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
Choice C rationale:
This choice correctly states that the cervix is dilated 3 cm, effaced 30%, and the presenting part is 1 cm above the ischial spines. This matches the documentation provided.
Choice D rationale:
This choice incorrectly states that the cervix is effaced 3 cm and dilated 30%. Effacement is measured in percentages, not centimeters, and dilation is measured in centimeters, not percentages. Additionally, it incorrectly states that the presenting part is 1 cm below the ischial spines. A station of -1 means the presenting part is 1 cm above the ischial spines.
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