The nurse is assessing a patient who has severe preeclampsia. The assessment finding that should be reported to the physician is:

2+ Deep Tendon Reflexes.

Platelets of 20,000

Urine output of 75 ml per hour.

1+ proteinuria.

Answer and Explanation

The Correct Answer is B

A. 2+ Deep Tendon Reflexes. A 2+ deep tendon reflex is considered normal and does not indicate worsening preeclampsia. Severe preeclampsia is often associated with hyperreflexia, typically 3+ or 4+, which can signal worsening central nervous system involvement and an increased risk for seizures.

B. Platelets of 20,000. A platelet count of 20,000 is dangerously low and suggests the development of HELLP syndrome, a severe complication of preeclampsia that includes hemolysis, elevated liver enzymes, and low platelets. This condition increases the risk of spontaneous bleeding and requires immediate medical intervention.

C. Urine output of 75 ml per hour. A urine output of 75 mL per hour is adequate and does not indicate worsening kidney function. In severe preeclampsia, oliguria (urine output less than 30 mL per hour) is a more concerning sign, as it suggests impaired renal perfusion and possible acute kidney injury.

D. 1+ Proteinuria. While proteinuria is a key feature of preeclampsia, a 1+ reading is mild and not necessarily indicative of worsening disease. Severe preeclampsia is typically associated with proteinuria of 3+ or higher, along with other symptoms such as hypertension, headache, and visual disturbances.

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Correct Answer is C

Explanation

A. To prevent uterine atony. Suprapubic pressure is not used to prevent uterine atony. Uterine atony, which leads to postpartum hemorrhage, is managed through uterine massage and medications such as oxytocin.

B. To facilitate the delivery of the baby's head. The baby's head has already been delivered in shoulder dystocia. The emergency arises because the shoulders are stuck behind the pubic bone, requiring specific maneuvers to release them.

C. To facilitate the delivery of the baby's shoulders. Shoulder dystocia occurs when the anterior shoulder becomes impacted behind the maternal pubic bone, preventing delivery. Suprapubic pressure is applied to help dislodge the shoulder by compressing it downward, allowing it to pass under the pubic bone. This maneuver, along with the McRoberts position, is commonly used to resolve the dystocia.

D. To prepare for the third stage of labor. The third stage of labor refers to the delivery of the placenta, which occurs after the baby is born. Suprapubic pressure is specifically used to assist in the second stage of labor when shoulder dystocia occurs.

A. Stay with the patient and call for help B. Suction the mouth to prevent aspiration C. Insert an oral airway D. Administer oxygen by tight face mask

Correct Answer is A

Explanation

A. Stay with the patient and call for help. The priority during a seizure is to ensure the patient’s safety and call for immediate assistance. The nurse should stay with the patient, protect her from injury, and note the seizure’s duration and characteristics. After the seizure ends, further interventions can be implemented.

B. Suction the mouth to prevent aspiration. Suctioning should only be performed after the seizure ends. Attempting to suction during an active seizure increases the risk of injury and airway obstruction.

C. Insert an oral airway. Inserting an oral airway during an active seizure is unsafe and contraindicated because it may cause trauma to the mouth or airway. An airway can be inserted after the seizure stops if necessary.

D. Administer oxygen by tight face mask. While oxygen is important, it should be provided after the seizure subsides and the airway is assessed. The primary focus during the seizure is safety, preventing injury, and calling for emergency assistance.

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The nurse is assessing a patient who has severe preeclampsia. The assessment finding that should be reported to the physician is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An emergency shoulder dystocia delivery occurred that requires the nurse to apply suprapubic pressure. What is the rationale for this action?

Correct Answer is C

Explanation

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to:

Correct Answer is A

Explanation

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