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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 D
Explanation
A. Fundus is at level of the umbilicus is well contracted and therefore, not of concern.
B. A saturated perineal pad in 15 min or less can indicate excessive bleeding.
C. Approximated edges of episiotomy indicate proper wound repair and therefore, not of concern.
D. Deep Tendon reflexes 4+-4+ are hyperactive and indicate the client is at greatest risk for preeclampsia and seizures; this is the priority.
Correct Answer is D
Explanation
Rationale
The client's respiratory rate of 10/min and absent deep-tendon reflexes are signs of magnesium sulfate toxicity, which can lead to respiratory depression and neuromuscular blockade. The nurse should stop the infusion immediately.
A Monitoring blood glucose is important, but not a priority.
B. Magnesium sulphate toxicity is not an indication for emergency delivery.
C. Placing the client in Trendelenburg position is not appropriate in this situation. trendelenburg position could worsen respiratory depression and compromise the client's airway.
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