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
Choice A rationale
Regular physical activity plays a key role in managing gestational diabetes. The American College of Obstetricians and Gynecologists (ACOG) recommends aiming for 150 minutes of moderate-level exercise each week during pregnancy. Reducing the exercise schedule to 3 days a week may not provide the recommended amount of physical activity needed to manage gestational diabetes effectively.
Choice B rationale
Glyburide is an oral medication that can be used to manage gestational diabetes when diet and exercise are not enough. It is usually taken before breakfast or the first main meal of the day.
Choice C rationale
This statement is correct. Women who have had gestational diabetes have an increased risk of developing type 2 diabetes later in life.
Choice D rationale
This statement is correct. A diet that includes about 40% to 45% carbohydrates is recommended for managing gestational diabetes.
Correct Answer is C
Explanation
Choice A rationale
While itching can be a side effect of opioid analgesics, it is not the priority observation. Itching can be uncomfortable for the client, but it is not life-threatening.
Choice B rationale
A temperature of 38.2°C (100.8°F) indicates a low-grade fever. While this should be monitored, it is not the priority observation in this situation.
Choice C rationale
The priority observation is the client’s blood pressure. Opioid epidural analgesia can cause hypotension, which can lead to inadequate perfusion to the mother and the fetus. Therefore, the nurse should prioritize monitoring the client’s blood pressure.
Choice D rationale
Weakness of the lower extremities can be a side effect of epidural analgesia, but it is not the priority observation. The nurse should monitor for this, but it is not as critical as monitoring the client’s blood pressure.
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