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29. A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
Nurses' Notes
0900:
Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
1000:
Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale, Reports feeling dizzy when they got up from examination table
Which of the following findings should the nurse report to the provider?
(Select all that apply.)
29. A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
Nurses' Notes
0900:
Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
1000:
Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale, Reports feeling dizzy when they got up from examination table
Which of the following findings should the nurse report to the provider?
(Select all that apply.)
Cerebral manifestations
Gastrointestinal assessment findings
Respiratory rate
Deep tendon reflexes
Blood pressure
Feral heart rate
Correct Answer : A,B,C,E,F
A The client reports a mild headache initially but then experiences a more severe headache along with dizziness. These symptoms could preeclampsia or gestational hypertension.
B. The client's presentations increase suspicion for preeclampsia which can lead to liver injury with right upper quadrant tenderness.
C. It is important to assess the respiratory rate as part of the overall evaluation of the client's condition considering the potential involvement of conditions like preeclampsia, which can affect multiple body systems.
E. The client's symptoms, including headache, dizziness, and inability to remove rings due to swelling, raise concerns for preeclampsia or gestational hypertension.
F. Monitoring fetal well-being is essential in the assessment of maternal conditions such as preeclampsia. If there are any concerns about fetal well-being, they should be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.
Correct Answer is C
Explanation
A firm, displaced fundus to the right of midline indicates a full bladder. A distended bladder can prevent the uterus from contracting properly and can lead to uterine atony, increasing the risk of postpartum hemorrhage. Therefore, the priority action is to have the client empty her bladder.
This can often be achieved by encouraging the client to urinate or by assisting her with toileting if necessary. Palpating a fundus that is firm and displaced does not indicate the need for fundal massage, as the fundus is already firm. Inserting a urinary catheter may be necessary if the client is unable to void spontaneously, but this should be done after attempting to have the client
urinate voluntarily. Administering an analgesic is not indicated based on the information provided.
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