A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation
Select the 5 findings that require follow up by the nurse
Nausea
DTR
Blood pressure
Fetal heart tracing
Weight assessment
Respiratory assessment
Fundal height
Lower extremity assessment
Correct Answer : B,C,E,G,H
A. Nausea, while uncomfortable, is a common symptom during pregnancy and should be addressed, but it is not as urgent as the other symptoms in this context.
B. The deep tendon reflex (DTR) being 3+ bilaterally indicates hyperreflexia, which can be associated with conditions like preeclampsia, hence the need for follow-up.
C. The elevated blood pressure reading of 148/94 mm Hg is indicative of hypertension, which could be a sign of preeclampsia, a serious pregnancy complication.
D. The fetal heart tracing, while important, does not show immediate concern with a rate of 140/min, which is within normal limits.
E. The weight gain of 0.68 kg (1.5 lb) within the last week is significant and could be indicative of fluid retention, which is concerning in the context of the client's other symptoms.
F. The respiratory rate of 20/min falls within the normal range, and there are no other indications of respiratory distress or abnormalities in the assessment findings provided. Therefore, respiratory assessment is not a priority for follow-up at this time.
G. The fundal height measurement of 29 cm is appropriate for 30 weeks of gestation, but given the other symptoms, it should be monitored for any rapid changes.
H. The presence of 1+ dependent edema noted bilaterally suggests fluid retention, which is a concerning finding and warrants further assessment to evaluate for signs of preeclampsia or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","F","G","I","J"]
Explanation
Yellowing of the eyes could indicate hepatotoxicity, a serious adverse effect associated with some of the anti-tuberculosis medications, particularly rifampin.
Blurred vision could be a sign of optic neuritis, a rare but serious adverse effect associated with ethambutol.
Abdominal pain could indicate hepatitis or hepatotoxicity, which are potential adverse effects of anti-tuberculosis medications like isoniazid and rifampin.
Increased bruising could indicate thrombocytopenia, a serious adverse effect associated with some anti-tuberculosis medications, particularly rifampin.
Increased bleeding tendency could also indicate thrombocytopenia or other hematologic abnormalities.
Red/orange tint to urine could indicate rifampin-induced discoloration of bodily fluids, which is not harmful but can be alarming to patients.
Darkening of urine could also be a result of rifampin-induced discoloration. It's important to differentiate between this harmless side effect and hematuria, which could indicate a more serious issue.
Correct Answer is B
Explanation
A. This advice may lead to inadequate emptying of the breasts and imbalance in milk production, potentially affecting milk supply and infant feeding.
B. Encouraging feeding on demand promotes effective breastfeeding by allowing the infant to feed when hungry, which helps establish and maintain milk supply. This approach supports infant cues and promotes successful breastfeeding.
C. Strict time limits on feeding can interfere with effective breastfeeding and hinder milk transfer, potentially leading to inadequate nutrition for the infant.
D. Water supplementation is unnecessary for breastfed infants and can interfere with breastfeeding by reducing infant appetite for breast milk.
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