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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Methylergonovine is a medication commonly used to prevent or treat postpartum hemorrhage, which is excessive bleeding after childbirth. It works by causing uterine contractions, which help to control bleeding by compressing blood vessels in the uterus. It is often administered following vaginal delivery to reduce the risk of excessive bleeding and complications associated with postpartum hemorrhage.

Correct Answer is []

Explanation

1. Potential Condition:

Hypoglycemia: The newborn is jittery and has decreased muscle tone, which are common signs of hypoglycemia (low blood sugar), especially in a newborn large for gestational age.

2. Actions to Take:

Check the newborn's capillary blood glucose level: This is crucial to confirm if hypoglycemia is the issue and to determine the appropriate treatment.
Place the newborn under a radiant warmer: This action helps stabilize the newborn’s body temperature, which is important as hypoglycemia can sometimes be associated with temperature instability.

3. Parameters to Monitor:

Temperature: Monitoring the temperature is important to ensure the newborn maintains normal body temperature and to identify any possible hypothermia.
Seizure activity: Jitteriness can sometimes progress to seizures if hypoglycemia is severe, so monitoring for seizure activity is critical.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?

Correct Answer is A

Explanation

A nurse is caring for a newborn. Exhibits Complete the diagram by specifying: The potential condition the newborn is most likely experiencing. Two actions the nurse should take to address that condition. Two parameters the nurse should monitor to assess the newborn's progress.

Correct Answer is []

Explanation

1. Potential Condition:

2. Actions to Take:

3. Parameters to Monitor:

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