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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

Explanation


One of the signs that the bladder may be distended is when the fundus (top of the uterus) is palpable to the right of the midline. This displacement indicates that the bladder is pushing the uterus to the side, which can occur when the bladder is full and obstructing the descent of the uterus into the pelvis during the postpartum period.

Correct Answer is C

Explanation


Allowing the baby to drain one breast at each feeding helps ensure effective milk removal, which can alleviate breast engorgement. Emptying the breast thoroughly promotes milk flow and prevents milk stasis, which contributes to engorgement.
A Cold compresses provide temporary relief from discomfort but does not address the underlying cause of engorgement.
B Drinking herbal tea, may have limited evidence supporting its efficacy in reducing engorgement. While hydration is important for breastfeeding, relying solely on herbal tea may not be as effective as other strategies.
D Feeding the baby every 2 hours, is important for maintaining milk supply and preventing engorgement. However, it's essential to ensure the breast is fully drained at each feeding, regardless of the time interval between feedings.

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