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.
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Related Questions
Correct Answer is D
Explanation
A: It's not the nurse's role to provide detailed information about the benefits of surgery on the informed consent form; this should be done by the provider.
B: Informing the client about their condition is primarily the provider's responsibility before obtaining consent.
C: The nurse should not be the one to explain the procedure; this is the provider's responsibility. The nurse ensures the client understands after the provider's explanation.
D: Confirming the client's signature is authentic is a crucial step for the nurse to ensure that the consent is valid and the client has indeed agreed to the procedure.
Correct Answer is A
Explanation
To calculate the IV infusion rate for dopamine hydrochloride, we first need to convert the dose from micrograms per kilogram per minute (mcg/kg/min) to milligrams per hour (mg/hr). The patient weighs 80 kg and the prescribed dose is 4 mcg/kg/min.
First, calculate the dose in mcg/hr: 4 mcg/kg/min x 80 kg x 60 min/hr = 19200 mcg/hr.
Next, convert mcg to mg: 19200 mcg/hr / 1000 mcg/mg = 19.2 mg/hr.
We have an 800 mg dopamine hydrochloride solution in a 250 mL bag. To find out how many mL/hr to administer, we use the following proportion:
(800 mg / 250 mL) = (19.2 mg / X mL).
Solving for X gives us X = (19.2 mg * 250 mL) / 800 mg, which equals 6 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 6 mL/hr.
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