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51. A nurse in an antepartum clinic is caring for a client who is pregnant.

Medical History 0815:

Gravida 4 Para 3

33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)

BMI 30.6

3.2 kg (7 lb) weight gain over the last 2 weeks

Select the 4 assessment findings the nurse should report to the provider.

A.

Deep tendon reflexes

B.

Visual disturbances

C.

Fetal heart rate

D.

Blood pressure

E.

Weight

Answer and Explanation

Correct Answer : C,D,E

Visual disturbances in a pregnant client could indicate conditions such as preeclampsia or gestational hypertension, which require immediate medical attention.

Monitoring the fetal heart rate is essential to assess fetal well-being, and any abnormalities in the fetal heart rate may require further evaluation by the provider.
Changes in blood pressure, especially elevated blood pressure, may indicate gestational hypertension or preeclampsia, which require monitoring and management by the provider. A significant weight gain of 3.2 kg (7 lb) over the last 2 weeks may indicate fluid retention or other issues that need assessment and intervention by the provider.
 
Deep tendon reflexes (option A) are not typically assessed routinely in antepartum care unless there are specific indications, such as signs of preeclampsia.
 


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Related Questions

Correct Answer is ["B","D","F"]

Explanation

Correct Choices for Indicating Understanding:

  • "I should make sure that my baby feeds 8 to 12 times per day."
  • "My baby's stools should turn to a yellow color within the next day or two."
  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

Rationale

  • "Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

    • This statement does not necessarily indicate an understanding of discharge teaching, as supplementation should only be done based on medical advice and not solely based on perceived weight loss.

  • "I should make sure that my baby feeds 8 to 12 times per day."

    • This statement indicates an understanding of discharge teaching, as frequent feeding is important for newborns to ensure adequate nutrition and hydration, and to promote milk production in breastfeeding mothers.

  • "I should cover my sore nipples with plastic-lined breast pads after every feeding."

    • This statement does not indicate proper understanding, as plastic-lined breast pads can retain moisture and increase the risk of infection. Instead, breathable pads or natural remedies are often recommended.

  • "My baby's stools should turn to a yellow color within the next day or two."

    • This statement indicates an understanding of normal neonatal stool changes, as breastfed babies' stools typically transition to a yellow color within a few days of birth.

  • "I can increase my milk supply by drinking more water."

    • While staying hydrated is important, this statement alone is insufficient for indicating a comprehensive understanding of increasing milk supply. Effective breastfeeding practices and frequent nursing are more directly impactful.

  • "I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

    • This statement indicates an understanding of the common experience of breast engorgement when milk comes in, which is a normal part of the breastfeeding process.

Correct Answer is A

Explanation

A hydatidiform mole (molar pregnancy), is a type of gestational trophoblastic disease characterized by abnormal and rapid growth of trophoblastic cells leading to uterine size that is large for gestational age
B. Molar pregnancy leads to elevated hCG levels not a decline.

C. Vaginal discharge in molar pregnancy is bloody with grape like vesicles.

D. Molar pregnancy does not yield into a viable fetus.

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