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.
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Correct Answer is A
Explanation
Choice A rationale
Postpartum hemorrhage is a serious condition characterized by heavy bleeding after childbirth. In the scenario described, the nurse’s notes indicate that the client’s fundus is boggy and located 1 cm above the umbilicus, which becomes firm with massage. This could be a sign of uterine atony, a leading cause of postpartum hemorrhage. Additionally, the client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10, and the perineal pad shows a moderate amount of lochia rubra. These are all signs that could indicate a postpartum hemorrhage.
Choice B rationale
While infection is a possible postpartum complication, the symptoms provided do not strongly indicate an infection. Symptoms of a postpartum infection typically include soreness, tenderness, or swelling of the belly or abdomen, chills, pain while urinating or during sex, abnormal vaginal discharge that has a bad smell or blood in it, and a general feeling of discomfort or unwellness.
Choice C rationale
Thrombophlebitis is a condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow. It commonly occurs in the legs but can occur elsewhere in the body. The symptoms include swelling of the affected area, redness of the affected area, tenderness of the affected area, warmth around the affected area, and pain. However, the symptoms provided do not strongly indicate thrombophlebitis.
Choice D rationale
Pulmonary embolism is a serious condition that occurs when a blood clot gets lodged in an artery in the lung, blocking blood flow to part of the lung. Symptoms can include shortness of breath or chest pain. However, the symptoms provided do not strongly indicate a pulmonary embolism.
Correct Answer is A
Explanation
Choice A rationale
Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.
Choice B rationale
Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.
Choice C rationale
Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.
Choice D rationale
Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.
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