A nurse in an antepartum clinic is caring for a client who is pregnant. Select the assessment findings the nurse should report to the provider.
Gravida 4 Para 3 33 weeks of gestation.
Allergies: Sulfa.
Height 165 cm (66 in) Weight 82 kg (180 lb) BMI 30.6.
32 kg(7 lb) weight gain over the last 2 weeks.
The Correct Answer is D
Choice A rationale
Gravida 4 Para 3 at 33 weeks of gestation is not an alarming finding. It simply indicates that the woman is pregnant for the fourth time and has had three previous deliveries. This is a normal part of the woman’s obstetric history and does not need to be reported to the provider.
Choice B rationale
Allergies, such as a sulfa allergy, are important to note in the patient’s medical history. However, unless the patient is being prescribed a medication that she is allergic to, this information does not need to be urgently reported to the provider.
Choice C rationale
A height of 165 cm (66 in), weight of 82 kg (180 lb), and BMI of 30.6 are all within normal ranges for a pregnant woman. These measurements are part of routine prenatal care and do not need to be urgently reported to the provider.
Choice D rationale
A weight gain of 32 kg (7 lb) over the last 2 weeks is concerning. Rapid weight gain can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure. This should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Documenting the findings and continuing to monitor the client is appropriate because the nurse has already observed that the fundus is midline and firm, which indicates good uterine tone. The presence of lochia rubra and small clots is expected in the immediate postpartum period.
Choice B rationale: Encouraging the client to empty her bladder can help maintain uterine tone, but in this scenario, the fundus is already firm and midline, so this is not the priority action.
Choice C rationale: Notifying the client's provider is unnecessary at this time because the findings are within normal postpartum expectations and the uterus is firm.
Choice D rationale: Increasing the frequency of fundal massage is not needed because the uterus is already firm and midline, indicating that it is contracting properly.
Correct Answer is A
Explanation
Choice A rationale: A postmature newborn, or one born after 42 weeks of gestation, is likely to exhibit cracked, peeling skin due to the prolonged exposure to amniotic fluid and the absence of vernix. This makes Choice A the correct answer, as it reflects the expected findings for a postmature newborn.
Choice B rationale: Abundant lanugo is typically seen in preterm infants, not postmature infants. Lanugo is a fine, downy hair that covers the fetus and usually disappears by 37 weeks of gestation. Therefore, Choice B is not an expected finding for a postmature newborn.
Choice C rationale: Short, soft fingernails are characteristic of preterm infants. In postmature infants, fingernails are generally long and may extend beyond the fingertips due to prolonged gestation. This makes Choice C an incorrect answer for the expected findings of a postmature newborn.
Choice D rationale: Abundant vernix is typically seen in preterm and term infants. Vernix is a white, cheesy substance that covers the fetal skin to protect it from amniotic fluid. Postmature infants usually have minimal to no vernix present, as it has already been absorbed. Therefore, Choice D is not an expected finding for a postmature newborn.
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