A nurse is assisting in the care of a client who is 36 weeks of gestation and reported to the clinic for a routine visit. 

Exhibits

Which of the following findings should the nurse report to the provider?.

Choice A rationale:

The nurse does not need to report the blood pressure finding. While blood pressure is an essential vital sign to monitor during pregnancy, the scenario does not indicate any abnormalities or concerning values in the client's blood pressure. Therefore, there is no immediate cause for reporting this finding.

Choice B rationale:

The nurse should report cerebral manifestations to the provider. The client's complaint of a more severe headache, rated at 5 on a 0 to 10 pain scale, along with feeling dizzy when getting up from the examination table, may indicate potential neurological symptoms. These could be signs of conditions like preeclampsia, which is a serious pregnancy complication characterized by high blood pressure and signs of damage to other organ systems, including the brain.

Choice C rationale:

The nurse should also report fetal heart rate findings to the provider. The client reports occasional contractions and positive fetal movement, but there is no mention of fetal heart rate in the nurse's notes. Monitoring the fetal heart rate is crucial during prenatal care, as changes in fetal heart rate could indicate fetal distress or other complications.

Choice D rationale:

The nurse does not need to report respiratory rate findings. There is no indication in the nurse's notes of any respiratory issues or complaints from the client, making this finding less relevant to the current situation.

Choice E rationale:

The nurse does not need to report deep tendon reflexes in this context. Deep tendon reflexes are not typically a priority assessment during routine prenatal care unless there are specific concerns or indications of neurological issues.

Choice F rationale:

The nurse does not need to report gastrointestinal assessment findings based on the information provided in the scenario. While the client reports "heartburn,”. there are no other gastrointestinal symptoms or indications of acute gastrointestinal issues requiring immediate reporting.

Choice A rationale:

Rh incompatibility is not relevant in this scenario. Rh incompatibility refers to a condition where the mother's blood is Rh-negative, and the baby's blood is Rh-positive, which can lead to hemolytic disease of the newborn. However, this condition is unrelated to the client's current presentation of heavy, red vaginal bleeding without contractions.

Choice B rationale:

Frequency and duration of contractions are not the primary concern in this situation. The client's main complaint is heavy vaginal bleeding without contractions, which indicates a potential issue with the placenta or other pregnancy-related problems.

Choice C rationale:

Fetal lung maturity is not the priority at this stage. The client is at 38 weeks of gestation, which is considered full term. Fetal lung maturity is typically assessed if there's a need for early delivery, which is not indicated in this scenario.

Choice D rationale:

The correct choice. The client is experiencing heavy, red vaginal bleeding, which may be a sign of placental abruption, where the placenta separates from the uterine wall prematurely. Determining the location of the placenta through an ultrasound can help identify if placental abruption is the cause of bleeding. Placental abruption can be a serious condition that requires immediate medical attention.