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 C
Explanation
A. While metronidazole is an antimicrobial medication, it does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
B. Ampicillin sodium is an antibiotic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
C. Doxorubicin hydrochloride is a cytotoxic chemotherapy medication that poses a significant biohazard risk due to its potential carcinogenic and mutagenic properties. Specific facility procedures for handling cytotoxic spills should be followed.
D. Phenytoin is an antiepileptic medication and does not pose a significant biohazard risk, and standard precautions for medication spills would suffice.
Correct Answer is B
Explanation
A. While revising the current policy for catheter care may be necessary, it is not the first step in addressing the increase in infections. Understanding the factors contributing to the infections is crucial before policy revision.
B. Identifying possible precipitating factors related to the infections is the first step in addressing the issue. This involves investigating the circumstances surrounding the infections to determine potential causes and contributing factors.
C. While staff training is important, scheduling training before understanding the root cause of the infections may not effectively address the problem.
D. Meeting with providers to discuss measures to decrease infections may be necessary, but it should occur after identifying the precipitating factors to ensure targeted and effective interventions.
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