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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: The correct answer is (a) Bleeding. The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding complications. Vitamin K plays a crucial role in the synthesis of blood clotting factors, specifically factors II, VII, IX, and X. Newborns have low levels of vitamin K at birth, and it takes a few days for their bodies to start producing it. This places them at risk of developing vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding problems, including bleeding into the brain (intracranial haemorrhage). By giving the newborn a vitamin K injection, this deficiency is corrected, reducing the risk of bleeding complications.
Choice B rationale
(b) Infection. Administering vitamin K to a newborn is not intended to prevent infections. Vitamin K is essential for blood clotting and does not have a direct role in preventing or treating infections. Infection prevention measures involve proper hygiene practices and vaccination, but vitamin K is unrelated to this aspect of care.
Choice C rationale
(c) Potassium deficiency. Administering vitamin K to a newborn has no impact on potassium levels. Potassium is a different essential nutrient that plays a vital role in various physiological processes, but it is not related to blood clotting. The administration of vitamin K is specific to preventing bleeding complications, not addressing potassium deficiency.
Choice D rationale
(d) Hyperbilirubinemia. The correct answer is not (d) Hyperbilirubinemia. Vitamin K administration is not aimed at preventing or treating hyperbilirubinemia, a condition characterized by elevated levels of bilirubin in the blood. Hyperbilirubinemia is related to the breakdown of red blood cells and the liver'sability to process bilirubin, whereas vitamin K's primary role is in the clotting cascade.
Correct Answer is ["A","B","E"]
Explanation
The correct answers are choices A. Blood pressure, B. Cerebral manifestations, and E. Deep tendon reflexes.
Choice A rationale:
Blood pressure is a critical parameter to monitor, especially in the third trimester. Elevated blood pressure can indicate preeclampsia, a serious condition that requires immediate attention.
Choice B rationale:
Cerebral manifestations, such as headaches or visual disturbances, can also be signs of preeclampsia. These symptoms should be reported to the provider immediately.
Choice C rationale:
The fetal heart rate of 158/min is within the normal range (110-160 beats per minute) and does not need to be reported.
Choice D rationale:
The respiratory rate is not mentioned in the provided notes, and there is no indication that it is abnormal. Therefore, it does not need to be reported.
Choice E rationale:
Deep tendon reflexes that are hyperactive (3+) can be a sign of preeclampsia. This finding should be reported to the provider.
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