A nurse is caring for a client who is pregnant and reports constipation. Which of the following recommendations should the nurse make?

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:

The nurse should not advise the client to take deep, cleansing breaths before and after each contraction because it can interfere with the natural urge to push and may not be effective in helping with the labor process. When a client feels the urge to push, it is essential to work with their body's natural instincts.

Choice B rationale:

Instructing the client to hold their breath and push while counting to ten is not recommended. This Valsalva manoeuvre can cause a sudden increase in intra-abdominal pressure, which may reduce blood flow to the heart and brain and may be harmful to both the client and the baby. It's crucial to promote safe pushing techniques during labor.

Choice C rationale:

The instruction to push continuously throughout the entire contraction is also not ideal. Pushing continuously can lead to exhaustion and decrease the effectiveness of each push. It's essential to guide the client on when and how to push effectively to prevent unnecessary fatigue.

Choice D rationale:

The correct instruction is to let the client know when to push according to their contractions. The urge to push is a natural reflex that signifies the baby's descent into the birth canal. The nurse should encourage the client to listen to their body and push when they feel the urge during the contractions. This approach optimizes the client's efforts and conserves their energy for delivery.