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","D","E"]

Explanation

A. Obtain equipment to start a 24-hour urine test on the patient. A 24-hour urine test is not necessary for placenta previa. It is more commonly used for preeclampsia to assess proteinuria, which is unrelated to placenta previa.

B. Obtain equipment for a manual pelvic exam. A manual pelvic exam is contraindicated in placenta previa because it can cause further disruption of the placenta, leading to severe hemorrhage. Instead, diagnosis should be confirmed using ultrasound.

C. Prepare to draw blood for a hemoglobin and hematocrit. Hemoglobin and hematocrit levels must be monitored due to the risk of maternal hemorrhage in placenta previa. Significant blood loss can lead to anemia and may require blood transfusions.

D. Obtain equipment for external electronic fetal heart rate monitoring. Continuous fetal monitoring is essential in placenta previa to assess for signs of fetal distress. External monitoring is preferred to avoid vaginal examinations, which could worsen bleeding.

E. Prepare the patient for an ultrasound. Ultrasound is the diagnostic test of choice for placenta previa. It helps determine the exact location of the placenta and confirms whether it is covering the cervix. A transabdominal ultrasound is performed first, followed by a transvaginal ultrasound if necessary.

A. Eclampsia B. Abruptio placentae C. Rupture of the uterus D. Placenta previa

Correct Answer is B

Explanation

A. Eclampsia. Eclampsia is characterized by seizures in a patient with preeclampsia, but it does not cause dark red vaginal bleeding, a tense abdomen, or increased contraction frequency. While eclampsia is a serious complication, the symptoms described are more indicative of placental abruption.

B. Abruptio placentae. Abruptio placentae (placental abruption) occurs when the placenta prematurely separates from the uterine wall, causing painful, dark red vaginal bleeding, frequent contractions, and a tense, rigid uterus (uterine hypertonicity). This is a medical emergency because it can lead to severe fetal distress, maternal hemorrhage, and disseminated intravascular coagulation (DIC).

C. Rupture of the uterus. Uterine rupture presents with sudden, severe abdominal pain, loss of fetal station, and fetal distress, often with maternal hemodynamic instability. While it is an emergency, it is more commonly associated with a history of prior uterine surgery (such as a cesarean section), which is not mentioned in this case.

D. Placenta previa. Placenta previa presents with painless, bright red vaginal bleeding, not dark red bleeding with severe pain and uterine hypertonicity. Placenta previa is caused by an abnormally implanted placenta over the cervix, but it does not typically cause a firm, tense uterus or excessive contractions.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse is preparing for the admission of a 30 weeks' gestation patient experiencing vaginal bleeding with a suspected diagnosis of placenta previa. In anticipating the patient's needs, which of the following would be most appropriate for the nurse to include? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is B

Explanation

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