-
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 ["A","C","D"]
Explanation
A.The client should limit carbohydrate intake to reduce the risk of gestational diabetes and its complications both in the mother and the fetus.
Glucose monitoring should be done 4 times daily.
C. Metformin is commonly prescribed to manage glucose levels in pregnant individuals with GDM.
D. The client's history of macrosomic newborns and family history of type 1 diabetes mellitus indicate an increased risk for complications such as fetal macrosomia and fetal distress. Nonstress tests are used to assess fetal well-being by monitoring fetal heart rate patterns.
E. With a BMI of 32 and a history of macrosomic newborns, the client is at an increased risk for developing gestational diabetes mellitus (GDM). Regular exercise is important in managing blood glucose levels and reducing the risk of GDM.
Correct Answer is A
Explanation
Late decelerations on the fetal monitor tracing indicate uteroplacental insufficiency, which can compromise fetal oxygenation. When membranes rupture and late decelerations occur, it's essential to take immediate action to improve fetal oxygenation.
Turning the client onto her side can help improve uteroplacental perfusion by relieving pressure on the vena cava and increasing blood flow to the uterus. This is the initial recommended intervention to optimize fetal oxygenation in the presence of late decelerations.
B. Increasing IV fluid infusion rate may be considered to optimize maternal hydration and potentially improve uteroplacental perfusion. However, it may not be the first action taken in response to late decelerations.
C. Palpating the client's uterus can provide information about uterine activity and may help assess for uterine hyperstimulation, which can contribute to fetal distress. However, in the context of late decelerations, the priority is to address potential uteroplacental insufficiency and optimize fetal oxygenation.
D. Administering oxygen to the client helps increase maternal oxygenation, which in turn improves fetal oxygenation. Oxygen administration is done after positing the client on to the lateral position.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
