A nurse is assisting with the care of client in a clinic.

Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

Rationale for correct choices:

• Placental abruption: The client exhibits sudden-onset hypertension, epigastric pain, headache, and facial edema at 30 weeks gestation, which are risk factors for placental abruption. Abruption involves premature separation of the placenta from the uterine wall, leading to maternal and fetal compromise. Early recognition is critical due to potential hemorrhage, fetal distress, and preterm delivery.

• Hypertension: The client’s blood pressure readings (148/94 mm Hg and 156/96 mm Hg) are significantly elevated for gestation, indicating preeclampsia or gestational hypertension. Hypertension increases the risk for placental abruption by causing vascular injury and reduced placental perfusion.

Rationale for incorrect choices:

• Postpartum hemorrhage: Postpartum hemorrhage occurs after delivery and is not a risk during the antepartum period at 30 weeks. While abruption can lead to bleeding, postpartum hemorrhage specifically refers to hemorrhage after birth and is not directly indicated by current findings.

• Placenta previa: Placenta previa involves implantation of the placenta over or near the cervical os, often presenting with painless vaginal bleeding. The client reports epigastric pain, headache, and hypertension, which are not characteristic of placenta previa.

• Hyperreflexia: While hyperreflexia is noted (DTRs 3+ bilaterally) and may indicate preeclampsia, it is a clinical finding rather than a direct cause of placental abruption. It is an important assessment parameter but does not independently increase the risk of abruption.

• Vomiting: Vomiting is a symptom the client reports but is not a primary risk factor for placental abruption. It may indicate associated preeclampsia or general discomfort but does not contribute directly to vascular placental separation.

A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give.

B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system.

C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults).

D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.