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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale :
Scrambled eggs. Taking ferrous sulfate with scrambled eggs is not the optimal choice because eggs contain phytates, which can bind to iron and reduce its absorption. Therefore, it may hinder the effectiveness of the iron supplement, and the client may not receive the full benefit of the medication.
Choice B rationale
A high-fibre meal. While fiber is generally beneficial for digestion and overall health, it is not the best choice to take with ferrous sulfate. Fiber can also interfere with iron absorption in the same way as phytates, potentially reducing the medication's effectiveness.
Choice C rationale
Orange juice. The nurse should instruct the client to take the ferrous sulfate with orange juice. Orange juice is an excellent choice because it is rich in vitamin C. Vitamin C enhances the absorption of non-heme iron (the type of iron found in plant-based sources like ferrous sulfate). By taking the medication with orange juice, the client can maximize the absorption of iron and improve the treatment of iron-deficiency anaemia.
Choice D rationale
Milk. Consuming ferrous sulfate with milk is not advisable. Calcium, present in milk, can inhibit the absorption of iron. Therefore, taking the medication with milk might reduce the efficacy of the iron supplement and not provide the desired therapeutic effect.
Correct Answer is D
Explanation
Choice A rationale:
Helping the client to the bathroom to empty her bladder is not the appropriate response in this situation. The client's sudden urge to push indicates that she is in the second stage of labor, which is the pushing phase. The cervix is already dilated at 7 cm, and the fetus is at 1+ station, indicating that delivery is imminent. Emptying the bladder at this point is not a priority and may delay necessary actions.
Choice B rationale:
Assisting the client into a comfortable position is also not the appropriate response. The client's urge to push suggests that she is in the active stage of labor, and her cervix is already 7 cm dilated. Encouraging a comfortable position might not be suitable since the focus should be on monitoring the progress of labor and preparing for delivery.
Choice C rationale:
Having the client pant during the next few contractions is not the correct response either. Panting is typically recommended during the transition phase of labor to prevent rapid pushing and potential damage to the perineum. However, in this scenario, the client is already fully dilated, and the fetus is at 1+ station, indicating that the second stage of labor has commenced. Panting is not necessary at this point.
Choice D rationale:
The appropriate nursing response is to assess the perineum for signs of crowning. The sudden urge to push indicates that the baby is descending through the birth canal and may be close to crowning, which is when the baby's head becomes visible at the vaginal opening. By assessing for crowning, the nurse can determine if delivery is imminent and notify the healthcare provider for further actions and preparation for the baby's birth.
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