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 ["A","B","C"]

Explanation

A. Frequent monitoring of vital signs. A post-dural puncture headache (PDPH) can occur after epidural anesthesia due to leakage of cerebrospinal fluid (CSF). Monitoring vital signs, particularly blood pressure and heart rate, helps assess for hypotension, fluid balance, and overall neurological status.

B. Assisting with a blood patch procedure. An epidural blood patch is the most effective treatment for a severe post-dural puncture headache. This procedure involves injecting the patient’s own blood into the epidural space to seal the CSF leak and relieve symptoms. The nurse should prepare for the procedure and educate the patient about it.

C. Administration of oral analgesics. Oral analgesics, such as acetaminophen or ibuprofen, are used to relieve mild to moderate headache symptoms. However, they may not be fully effective for a severe PDPH and are often used as supportive therapy along with other interventions.

D. Keeping the head of bed elevated at all times. Lying flat, rather than elevating the head of the bed, is actually recommended to help reduce CSF leakage and alleviate headache symptoms. Keeping the head elevated may worsen the headache by increasing CSF pressure changes.

A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B. Effects on the fetus and newborn can include decreased alertness and delayed sucking C. Intravenous (IV) patient-controlled analgesia (PCA) results in increased use of an analgesic D. Intramuscular (M) administration is preferred over IV administration

Correct Answer is B

Explanation

A. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. While systemic analgesics do cross the placenta, they actually affect the fetus more readily than the mother because the fetal liver and kidneys are immature, making drug metabolism and excretion slower. This leads to prolonged effects on the newborn.

B. Effects on the fetus and newborn can include decreased alertness and delayed sucking. Opioid analgesics, such as fentanyl, meperidine, or morphine, can cause neonatal respiratory depression, reduced alertness, and difficulty initiating breastfeeding due to delayed sucking reflex. If administered too close to delivery, the newborn may require respiratory support or naloxone to reverse opioid effects.

C. Intravenous (IV) patient-controlled analgesia (PCA) results in increased use of an analgesic. PCA allows controlled dosing of pain medication, often leading to less total medication use because the patient receives smaller, more frequent doses rather than large, single doses. This helps maintain stable pain control without excessive sedation.

D. Intramuscular (IM) administration is preferred over IV administration. IV administration is preferred over IM because it provides faster pain relief and better dose control. IM injections have delayed absorption and an unpredictable effect, making IV the preferred route for labor analgesia.

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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

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Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is B

Explanation

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