A nurse is caring for a client who is pregnant in a provider's office. Vital Signs. Medical History. 0830:. Medical History: Gravida 3 Para 2. 32 weeks of gestation. Allergies: Penicillin. Height 54, 163 cm. Weight 80.7 kg (178 lb). BMI 30.6. 6 lb weight gain over the last 2 weeks. The client reports, "I have had a headache for 5 days, blurred vision, and dizziness. Tylenol does not relieve it.". The client reports swelling of their feet and fingers. 2+ pitting edema of the lower extremities noted bilaterally. Swelling of the fingers and hands noted. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FHT) 148. Which of the following findings should the nurse report to the provider?
Visual disturbances.
Blood pressure.
Respirations.
Deep tendon reflexes.
Weight.
The Correct Answer is A
Choice A rationale:
Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.
Choice B rationale:
Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.
Choice C rationale:
Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.
Choice D rationale:
Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.
Choice E rationale:
Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.
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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
Choice A reason:
Initiating epidural anesthesia too soon may delay rupture of fetal membranes. This statement is not accurate. Epidural anesthesia itself does not have a direct impact on the rupture of fetal membranes. The timing of rupturing membranes is determined based on the progress of labor and other clinical indications. There is no causal relationship between epidural anesthesia and the timing of membrane rupture.
Choice B reason:
Initiating epidural anesthesia too soon can prolong labor. This statement is correct. Epidural anesthesia, while providing pain relief during labor, can also cause some degree of motor blockage and decrease the woman's ability to push effectively. This can potentially lead to a lengthening of the labor process. It is generally recommended to wait until a good labor pattern has been established to avoid unnecessary prolongation of labor.
Choice C reason:
Initiating epidural anesthesia too soon can cause fetal depression. This statement is not entirely accurate. Epidural anesthesia can cross the placenta and reach the fetus, but the effect on the baby is usually minimal. However, fetal monitoring is essential during labor to ensure the baby's well-being, regardless of whether epidural anesthesia is used or not.
Choice D reason:
Initiating epidural anesthesia too soon can cause maternal hypertension. This statement is not supported by evidence. Epidural anesthesia does not typically cause maternal hypertension. It can, however, lead to a decrease in blood pressure in some cases, which is why careful monitoring of maternal blood pressure is necessary during and after the administration of epidural anesthesia.
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