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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Related Questions
Correct Answer is D
Explanation
A. Early decelerations are usually benign and are associated with head compression during contractions.
B. Accelerations are increases in the fetal heart rate above the baseline. They are typically reassuring and indicate fetal well-being.
C. Late decelerations are concerning patterns in fetal heart rate monitoring. They can indicate poor oxygenation of the fetus and may be associated with conditions such as maternal hypotension, placental insufficiency, or other factors compromising blood flow to the fetus.
D. Variable decelerations are abrupt decreases in fetal heart rate that vary in timing, duration, and depth. They are often associated with umbilical cord compression, such as when the cord is being compressed or squeezed during contractions.
Correct Answer is A
Explanation
Inserting a gloved hand into the vagina to relieve pressure on the cord. This helps to prevent compression and compromise of blood flow to the fetus.
The other cations can follow the relief of pressure i.e B, D, C
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