A nurse in a provider’s office is caring for a client who is pregnant.
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)

Answer and explanation
The correct answer is Choice D.
Choice A rationale
A respiratory rate of 16 breaths per minute is within the normal range for an adult, and would not typically be a cause for concern.
Choice B rationale
A Fetal Heart Rate (FHR) of 158 beats per minute is within the normal range (110-160 beats per minute) and would not typically be a cause for concern.
Choice C rationale
While a persistent headache can be a symptom of pre-eclampsia, it is not typically a reason to report to the healthcare provider when a patient is receiving magnesium sulfate to manage pre-eclampsia.
Choice D rationale
A urinary output of 40 mL in 2 hours is less than the normal range (at least 30 mL/hour). This could indicate kidney dysfunction, which is a serious complication of pre-eclampsia. Therefore, this observation should be reported to the healthcare provider.

Choice A rationale
While cigarette smoking can increase the risk of many complications during pregnancy, including placental abruption, it is not the most common risk factor. Smoking can cause constriction and damage to the blood vessels in the placenta, but other factors, such as hypertension, are more commonly associated with placental abruption.
Choice B rationale
Hypertension is the most common risk factor for placental abruption. High blood pressure can cause damage to the blood vessels in the placenta, leading to abruption. Chronic hypertension, gestational hypertension, and preeclampsia can all increase a woman’s risk of experiencing a placental abruption.
Choice C rationale
Blunt force trauma, such as that experienced in a car accident or a fall, can cause placental abruption, but it is not the most common risk factor. Any trauma to the abdomen during pregnancy should be evaluated by a healthcare provider to assess for potential complications, including placental abruption.
Choice D rationale
Cocaine use can increase the risk of placental abruption. Cocaine causes intense vasoconstriction, which can compromise the blood flow to the placenta and lead to abruption. However, it is not the most common risk factor for this condition.