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. Nurses' Notes. 0900:. Vital Signs. Physical Examination. Lungs clear to auscultation in all lobes, anterior, posterior, and lateral. Abdomen gravid and soft to palpation. Fundal height 37 cm. Facial edema observed as well as +3 edema in the lower extremities. Patellar reflex 3+, clonus negative. Fetal heart rate 158/min. Which of the following findings should the nurse report to the provider?. (Select all that apply.).

Choice A rationale:

Excessive uterine enlargement. Rationale: The nurse should monitor the client for excessive uterine enlargement, as a hydatidiform mole is a rare condition in pregnancy where abnormal placental tissue forms instead of a fetus. This abnormal growth can lead to uterine enlargement beyond the expected size for gestational age.

Choice B rationale:

Rapidly dropping human chorionic gonadotropin (hCG) levels. Rationale: The nurse should also monitor the client's hCG levels. In a normal pregnancy, hCG levels typically rise steadily during the early stages. However, in the case of a hydatidiform mole, hCG levels may either plateau or drop rapidly due to the abnormal placental growth.

Choice C rationale:

Fetal heart rate irregularities. Rationale: Although a hydatidiform mole does not involve a viable fetus, the nurse should still assess for fetal heart rate irregularities. In some rare cases, the presence of abnormal placental tissue can cause confusion in the diagnosis, and there may be coexisting fetal development. Fetal heart rate irregularities may indicate potential complications.

Choice D rationale:

Whitish vaginal discharge. Rationale: Whitish vaginal discharge is not typically associated with a hydatidiform mole. Instead, this finding is more commonly seen in other vaginal infections or conditions unrelated to a molar pregnancy. The nurse should be cautious not to misinterpret this symptom as a definitive sign of a hydatidiform mole.

The correct answer is choice B: Apply an ice pack to the perineum. This is the recommended action for unrelieved episiotomy pain within the first 24 hours following delivery, as it helps reduce swelling and provide pain relief.

Choice A rationale:

Placing a soft pillow under the client’s buttocks may provide comfort, but it does not directly address the inflammation and pain associated with an episiotomy. It is not the primary intervention for unrelieved episiotomy pain shortly after delivery.

Choice B rationale:

Applying an ice pack to the perineum is a standard practice for reducing pain and swelling after an episiotomy. The cold temperature causes vasoconstriction, which can help to decrease swelling and provide pain relief. This is especially effective within the first 24 hours post-delivery.

Choice C rationale:

Positioning a heating lamp toward the episiotomy is not recommended immediately following the procedure, as heat can increase blood flow to the area, potentially worsening swelling and pain in the acute phase after the surgery.

Choice D rationale:

While a warm sitz bath may be beneficial for episiotomy pain relief, it is typically recommended after the initial 24-hour period post-delivery. In the first 24 hours, cold therapy is preferred to reduce acute inflammation and pain.