During an assessment, a nurse is evaluating a pregnant client for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

Correct Answer: C

Rationale: In the assessment of a pregnant client for preeclampsia, the finding that should indicate to the nurse that the client requires further evaluation for this disorder is an elevated blood pressure (option C). Preeclampsia is characterized by high blood pressure (hypertension) that develops after 20 weeks of pregnancy. Elevated blood pressure is a key indicator of preeclampsia and requires immediate attention to prevent complications for both the mother and the baby. The other options are incorrect: A) Increased urine output: Increased urine output is not typically associated with preeclampsia. In fact, decreased urine output or oliguria is more commonly seen in severe cases of preeclampsia due to reduced kidney function. B) Vaginal discharge: Vaginal discharge is not a typical sign of preeclampsia. Preeclampsia is primarily characterized by hypertension, proteinuria, and sometimes edema. D) Joint pain: Joint pain is not a specific sign of preeclampsia. Preeclampsia symptoms usually involve hypertension, headaches, visual disturbances, and swelling, rather than joint pain. Educationally, understanding the signs and symptoms of preeclampsia is crucial for nurses caring for pregnant clients as early detection and management are essential to prevent serious complications such as eclampsia, seizures, and organ damage. Regular blood pressure monitoring and thorough assessments are critical in identifying preeclampsia promptly.

Correct Answer: B

Rationale: Pelvic pain is a common symptom of endometritis, which is an infection of the uterine lining. It is an important finding that warrants further evaluation. Localized area of breast tenderness may indicate mastitis, vaginal discharge with a foul odor could suggest a vaginal infection, and hematuria points towards a urinary tract issue, but they are not specific to endometritis.

Correct Answer: C

Rationale: In a pregnant woman with a temperature of 38.9°C (102°F) in early labor with ruptured membranes, assessing the odor of the amniotic fluid is crucial. Foul-smelling or malodorous amniotic fluid could indicate infection, such as chorioamnionitis, which poses risks to both the woman and the fetus. This assessment can help in determining if an infection is present and prompt appropriate interventions. Rechecking the temperature, administering glucocorticoids, or preparing for an emergency cesarean section are not the most immediate or appropriate actions in this scenario.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Abruptio placentae. Abruptio placentae is a condition where the placenta partially or completely peels away from the uterine wall before delivery. This can cause severe abdominal pain and vaginal bleeding, which are symptoms the client is experiencing. Let's discuss why the other options are incorrect: A) Placenta previa involves the placenta partially or fully covering the cervix, usually presenting with painless vaginal bleeding. This is not consistent with the client's symptoms of abdominal pain. B) Prolapsed cord is when the umbilical cord descends through the cervix ahead of the baby, which can lead to fetal distress but does not typically cause maternal abdominal pain. C) Incompetent cervix is characterized by painless cervical dilation in the second trimester, not typically causing sudden abdominal pain and bleeding in the third trimester. Educationally, understanding these differential diagnoses is crucial for nurses caring for pregnant clients. Recognizing the signs and symptoms of complications like abruptio placentae is vital for timely intervention, which can significantly impact maternal and fetal outcomes. This case emphasizes the importance of thorough assessment and critical thinking in maternal care to provide safe and effective nursing interventions.

Correct Answer: D

Rationale: In the scenario described, the client is experiencing heavy vaginal bleeding, which is concerning for placenta previa. The appropriate nursing action in this situation is to prepare for a cesarean birth. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to life-threatening bleeding during labor. It is crucial to avoid vaginal examinations or initiation of pushing as these actions can exacerbate bleeding. A magnesium sulfate infusion is not indicated in the management of placenta previa. Therefore, the priority intervention is to prepare for a cesarean birth to ensure the safety of the mother and the baby.