A nurse is assessing four clients in a prenatal clinic.
Which of the following clients should the nurse recommend that the provider see first?
A client who is at 12 weeks of gestation and reports not having felt the fetus move.
A client who is at 28 weeks of gestation and has a fetal heart rate of 160/min via Doppler.
A client who is at 38 weeks of gestation and has 2+ deep tendon reflexes.
A client who is at 36 weeks of gestation and reports blurred vision.
The Correct Answer is D
Choice A rationale
A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.
Choice B rationale
A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.
Choice C rationale
Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.
Choice D rationale
Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Depression is a common mental health condition and is not a contraindication for the use of a copper intrauterine device (IUD). The copper IUD is a non-hormonal contraceptive method, meaning it does not release hormones that could potentially interact with or exacerbate symptoms of depression. Therefore, it is a safe option for individuals with this condition.
Choice B rationale
Diabetes mellitus, when well-controlled, is not a contraindication for the use of a copper IUD. The copper IUD does not affect blood glucose levels or insulin sensitivity, making it a suitable contraceptive option for individuals with diabetes. Hormonal methods might require more careful consideration, but copper IUDs are generally safe.
Choice C rationale
Cholelithiasis, or gallstones, is a condition affecting the gallbladder and bile ducts. It is not a contraindication for the use of a copper IUD. The copper IUD's mechanism of action is local, primarily affecting the uterine environment, and does not involve systemic hormonal changes that would impact gallbladder function.
Choice D rationale
Dysmenorrhea, or painful menstruation, is a significant contraindication for the use of a copper IUD. The copper IUD is known to increase menstrual bleeding and cramping, which can worsen pre-existing dysmenorrhea. This potential exacerbation of symptoms can lead to client dissatisfaction and discontinuation of the method.
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via nasal cannula at 2 L/min might marginally increase fetal oxygenation, but it does not address the primary issue of hypotension causing decreased placental perfusion. The fundamental problem is reduced blood flow to the placenta, necessitating interventions that increase maternal circulating volume and blood pressure to improve perfusion.
Choice B rationale
Administering a lactated Ringer's 500 mL bolus directly addresses hypotension by expanding the maternal intravascular volume. This increased circulating volume raises blood pressure, thereby improving placental perfusion and oxygen delivery to the fetus. Lactated Ringer's is an isotonic solution, effective for rapid volume expansion.
Choice C rationale
Placing the client in a knee-chest position is typically used to alleviate cord compression or prolapse by shifting the fetus, not for treating hypotension. This position can actually worsen hypotension by trapping blood in the lower extremities and reducing venous return to the heart, further compromising placental blood flow.
Choice D rationale
Monitoring the client's blood pressure every 30 minutes is a crucial assessment but is not an immediate intervention for acute hypotension with decreased placental perfusion. While ongoing monitoring is essential, immediate actions are required to correct the underlying cause of hypotension and restore adequate blood flow to the placenta.
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