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 B

Explanation

While many women are able to get pregnant again after an ectopic pregnancy, it is not guaranteed. The ability to conceive again depends on various factors, such as:

The extent of damage to the fallopian tube.
Whether one or both tubes are still functional.
The treatment used (e.g., methotrexate vs. surgery).
Any underlying fertility issues.

It is important to be honest but reassuring, explaining that many women do go on to have healthy pregnancies, but future fertility can be affected and should be discussed with a healthcare provider. Saying she "absolutely will" get pregnant again is inaccurate and potentially misleading.

A. Midplane contracture of the pelvis B. Disproportion of the pelvis. C. Low-lying placenta D. Compromised bearing-down efforts as a result of pain medication

Correct Answer is C

Explanation

A. Midplane contracture of the pelvis. Pelvic contractures can lead to dystocia by restricting the fetal head's descent. A midplane contracture narrows the pelvic midsection, making labor prolonged and difficult. This is a common cause of dystocia.

B. Disproportion of the pelvis. Cephalopelvic disproportion (CPD), where the fetal head is too large for the maternal pelvis, is a well-known cause of dystocia. It often results in prolonged labor, failure to progress, and the need for cesarean delivery.

C. Low-lying placenta. A low-lying placenta does not directly cause dystocia. Instead, it may lead to placenta previa, which often requires cesarean delivery before labor even begins. Since it does not typically cause prolonged or difficult labor, it is the least common cause of dystocia.

D. Compromised bearing-down efforts as a result of pain medication. Excessive pain medication, especially epidurals or narcotics, can weaken maternal pushing efforts, leading to prolonged second-stage labor. This is a recognized cause of dystocia, particularly in multiparous women.

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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

A woman is admitted due to a suspected ectopic pregnancy. While explaining treatment the patient asks if she will be able to get pregnant again. You answer that she absolutely will get pregnant again. Is this the correct thing to say?

Correct Answer is B

Explanation

The least common cause of long. difficult, or abnormal labor (dystocia) is:

Correct Answer is C

Explanation

The nurse recognizes that a woman is in true labor when she states…., and finds that her cervix has dilated and effaced on examination.

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