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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 A
Explanation
A. Placental insufficiency can lead to inadequate nutrient and oxygen delivery to the fetus, resulting in intrauterine growth restriction (IUGR) and SGA.
B. Perinatal asphyxia refers to oxygen deprivation around the time of birth, can lead to various complications, including neurological damage, but it is not a direct cause of SGA.
C. While preterm delivery can lead to low birth weight and small size at birth, it is not a direct cause of SGA.
D. Fetal hyperinsulinemia, which occurs when the fetus produces excess insulin, can lead to macrosomia (large birth weight) rather than SGA.
Correct Answer is D
No explanation
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