A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago. Which of the following findings should the nurse report to the provider?
Pedal edema
BP of 132/84 mm Hg
Weight gain of 1 kg (2.2 lb)
Double vision
The Correct Answer is D
(a) Pedal edema
Pedal edema, or swelling of the feet and ankles, is a common finding during pregnancy due to increased fluid retention and pressure on the lower extremities from the growing uterus. While pedal edema should be monitored, it is not typically a concerning finding unless it is severe or accompanied by other symptoms suggestive of preeclampsia.
(b) BP of 132/84 mm Hg
A blood pressure of 132/84 mm Hg is within the normal range for pregnancy. However, if the client's blood pressure continues to increase or is accompanied by other symptoms of hypertension, such as proteinuria or headaches, it may warrant further evaluation.
(c) Weight gain of 1 kg (2.2 lb)
Weight gain during pregnancy is expected and can vary from person to person and from week to week. A weight gain of 1 kg (2.2 lb) over the course of a month is within the normal range for pregnancy and may not require immediate reporting to the provider unless there are other concerning symptoms.
(d) Double vision
Double vision (diplopia) can be a symptom of several conditions, including preeclampsia, which is a serious complication of pregnancy characterized by high blood pressure and proteinuria. Double vision can also be caused by other neurological or ophthalmologic conditions. Given its potential association with preeclampsia and other serious conditions, the nurse should promptly report double vision to the provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) "White blood cell count is an indicator of anemia.”
White blood cell count is not directly related to anemia. Anemia is typically assessed by hemoglobin and hematocrit levels, which reflect the oxygen-carrying capacity of the blood. White blood cell count measures immune system function and can indicate infection or inflammation rather than anemia.
(B) "Urine specific gravity identifies my risk for pregnancy induced hypertension.”
Urine specific gravity is a measure of urine concentration and hydration status, and it is not typically used to identify the risk of pregnancy-induced hypertension (preeclampsia). Preeclampsia is diagnosed based on symptoms such as hypertension (high blood pressure) and proteinuria (protein in the urine), along with other criteria.
(C) "Platelet count identifies if I am at risk for bleeding.”
Platelet count is a laboratory test that measures the number of platelets in the blood. Platelets are essential for blood clotting, so a low platelet count (thrombocytopenia) can indicate an increased risk of bleeding, which is pertinent to pregnancy, especially in cases of conditions like gestational thrombocytopenia or preeclampsia.
(D) "Sedimentation rate checks for signs of cancer.”
The sedimentation rate (ESR or sed rate) is a nonspecific test that measures inflammation in the body, but it is not used to check for signs of cancer specifically. Elevated sedimentation rate can indicate various inflammatory conditions such as infection, autoimmune diseases, or chronic inflammatory disorders. It is not a primary test for cancer diagnosis.
Correct Answer is A
Explanation
(A) "You should check the identity of individuals who come to remove your baby from the room":
It's crucial for parents to verify the identity of anyone who comes to take their baby out of the room. This helps ensure the baby's safety and prevents unauthorized individuals from taking the baby. Hospital staff usually wear identification badges, and parents should be encouraged to ask for and verify this identification.
(B) "We will scan your baby's identification bracelet each time check on him":
While scanning the baby's identification bracelet might be part of some hospital protocols for specific purposes like medication administration or matching mother and baby during certain procedures, it is not typically done every time a nurse checks on the baby. Continuous scanning is not a standard practice and would be logistically impractical.
(C) "We will match the bracelet on your baby with his footprint record each shift":
Matching the baby's bracelet with footprint records each shift is not a standard safety protocol. Footprints are usually taken at birth for records but are not routinely matched every shift. Identification is more reliably ensured through the use of identification bands worn by both the mother and the baby.
(D) "Your baby will wear an electronic bracelet when he is out of your room":
In many hospitals, electronic bracelets are used as a security measure, but they are typically worn by the baby at all times, not just when the baby is out of the room. This measure helps prevent abduction and ensures the baby's location is monitored continuously.
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