Difficulty: Medium
Average Score: 74%
Simulated
Passage / Scenario
Vital Signs at 0700 hrs: Temperature: 36.6°C (97.9°F), Pulse: 85/min, Respiratory rate: 20/min, Blood pressure: 180/99 mm Hg. Nurses' Notes at 0700 hrs: Client reports, "I have had a headache for 2 days. Tylenol does not relieve it." Client states, "I have blurred vision and dizziness." Client reports swelling of their feet. 2+ pitting edema of the lower extremities noted bilaterally. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FH) 150/min. Medical History: Gravida 4 Para 3, 33 weeks of gestation, Allergies: Sulfa, Height: 165 cm (66 in), Weight: 82 kg (180 lb), BMI: 30.6.Select the 4 assessment findings the nurse should report to the provider.
Correct answer
A, B, D, G
Rationale
Headache unrelieved by Tylenol, blurred vision and dizziness, 2+ pitting edema, and blood pressure of 180/99 mm Hg are concerning signs of preeclampsia, requiring immediate reporting. Swelling of feet is common and less urgent unless accompanied by other symptoms. Deep tendon reflexes 3+ and fetal heart tones 150/min are normal.