Which of the following clients should a nurse recommend that the provider see first when assessing four clients in a prenatal clinic?
A client who is at 12 weeks of gestation and reports not having felt the fetus move.
A client who is at 38 weeks of gestation and has 2+ deep tendon reflexes.
A client who is at 36 weeks of gestation and reports blurred vision.
A client who is at 28 weeks of gestation and has a fetal heart rate of 160/min via Doppler
The Correct Answer is C
Choice A reason: Not feeling fetal movement at 12 weeks is normal, as quickening typically begins at 16-20 weeks. Fetal movement is not expected this early due to small fetal size and limited neuromuscular development. This finding does not indicate an emergency, as it aligns with normal gestational physiology.
Choice B reason: 2+ deep tendon reflexes at 38 weeks are normal, reflecting intact neurological function. Hyperreflexia (3+ or 4+) may suggest preeclampsia, but 2+ is not concerning. Reflexes are influenced by magnesium levels and neurological status, but this finding does not prioritize immediate provider attention compared to urgent symptoms like blurred vision.
Choice C reason: Blurred vision at 36 weeks suggests preeclampsia, as cerebral edema or vasoconstriction affects visual pathways. This symptom indicates severe features, risking seizures or stroke. Preeclampsia’s endothelial dysfunction elevates blood pressure, impairing cerebral perfusion, making this a medical emergency requiring immediate provider evaluation to prevent maternal and fetal complications.
Choice D reason: A fetal heart rate of 160/min at 28 weeks is within the normal range (110-160/min), indicating fetal well-being. Doppler assessment reflects autonomic function and oxygenation, and this rate does not suggest distress. Unlike blurred vision, which signals maternal complications, this finding does not require urgent provider attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Acrocyanosis, a benign bluish discoloration of extremities, is common in healthy newborns due to immature peripheral circulation, not specific to neonatal abstinence syndrome (NAS). NAS involves central nervous system irritability from opioid withdrawal, causing symptoms like tachypnea or tremors, not peripheral vasoconstriction unrelated to withdrawal physiology.
Choice B reason: Hypotonia is not typical in neonatal abstinence syndrome, which causes hypertonia due to central nervous system irritability from opioid withdrawal. Hypotonia suggests other conditions, like neuromuscular disorders, not the hyperactive neurological state of NAS, where increased muscle tone and reflexes dominate due to autonomic dysregulation.
Choice C reason: Tachypnea is expected in neonatal abstinence syndrome, as opioid withdrawal causes autonomic hyperactivity, increasing respiratory drive. The newborn’s immature nervous system responds to withdrawal stress with rapid breathing, reflecting heightened metabolic demand and sympathetic activation, a hallmark of NAS requiring careful monitoring to prevent respiratory distress.
Choice D reason: A shrill pitched cry is a classic finding in neonatal abstinence syndrome, indicating central nervous system irritability from opioid withdrawal. The high-pitched cry reflects neurological overstimulation, as the infant’s brain struggles to regulate without opioid exposure, distinguishing NAS from normal newborn behavior and requiring supportive care.
Choice E reason: An exaggerated Moro reflex is expected in neonatal abstinence syndrome, as withdrawal heightens neurological excitability. The reflex, triggered by sudden movement, is amplified due to central nervous system irritability, reflecting the infant’s hypersensitive autonomic response to opioid withdrawal, necessitating calming interventions to reduce overstimulation.
Correct Answer is A
Explanation
Choice A reason: A change in deep tendon reflexes from 4+ (hyperreflexic) to 2+ (normal) indicates magnesium sulfate’s therapeutic effect in preeclampsia, as it reduces neuronal excitability, preventing seizures. Magnesium stabilizes nerve membranes, lowering seizure risk by modulating calcium channels, aligning with its anticonvulsant role in preeclampsia management.
Choice B reason: A fetal heart rate increase from 150/min to 166/min is not a direct indicator of magnesium sulfate’s effectiveness. Magnesium primarily prevents maternal seizures, not fetal heart rate changes. This increase may reflect fetal stress or normal variation, unrelated to magnesium’s neurological stabilization in preeclampsia treatment.
Choice C reason: Minimal fetal heart rate variability suggests fetal compromise, not magnesium sulfate’s desired effect. Magnesium aims to prevent maternal seizures without significantly altering fetal heart patterns. Reduced variability may indicate hypoxia, requiring separate intervention, as it does not reflect the drug’s therapeutic goal of maternal neurological stabilization.
Choice D reason: Urinary output of 20 mL/hr indicates potential magnesium toxicity or renal impairment, not therapeutic effectiveness. Magnesium sulfate requires adequate renal excretion to avoid toxicity, and output below 30 mL/hr suggests accumulation, risking respiratory depression or cardiac effects, contrary to the drug’s intended anticonvulsant action in preeclampsia.
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