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.
Deep tendon reflexes
Visual disturbances
Fetal heart rate
Blood pressure
Weight
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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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 B
Explanation
True labor is characterized by characteristic lower abdominal pain that in frequency and intensity and radiate to the back with progressive changes in the cervix, including effacement and dilation. A, C and D are not reliable features of true labor.
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