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 A
Explanation
(a) Offer an ice pack to the client during the first 24 hr.
Offering an ice pack is an appropriate intervention for managing perineal pain and swelling in the immediate postpartum period. Ice helps to reduce inflammation and numb the area, providing pain relief. This is a standard recommendation for managing perineal pain after vaginal delivery.
(b) Apply a corticosteroid cream to the perineal area twice daily.
Applying a corticosteroid cream is not typically recommended for perineal pain immediately after delivery. These creams are generally used for inflammatory skin conditions and not for the acute management of perineal pain and swelling after childbirth.
(c) Increase the client's fluid intake for 48 hr.
While maintaining adequate hydration is important for overall recovery, increasing fluid intake specifically does not address the client's perineal pain. This intervention would not provide immediate pain relief for the perineal area.
(d) Catheterize the client's bladder.
Catheterizing the bladder is not a standard intervention for perineal pain. It is typically done if the client has urinary retention or difficulty voiding, not for managing pain. This action would not directly alleviate the perineal pain the client is experiencing.
Correct Answer is C
Explanation
(a) "White blood cell count is an indicator of anemia."
A white blood cell (WBC) count is primarily used to assess for infection or inflammation, not anemia. Anemia is typically evaluated by measuring hemoglobin and hematocrit levels, not WBC count. This statement indicates a misunderstanding of the purpose of the WBC count.
(b) "Urine specific gravity identifies my risk for pregnancy induced hypertension."
Urine specific gravity measures the concentration of urine and is used to assess hydration status and kidney function. It does not directly identify the risk for pregnancy-induced hypertension (PIH). The presence of protein in the urine (proteinuria) would be more indicative of PIH. This statement indicates a misunderstanding of the purpose of the urine specific gravity test.
(c) "Platelet count identifies if I am at risk for bleeding."
This is the correct statement. A platelet count is used to determine the number of platelets in the blood, which are essential for normal blood clotting. A low platelet count (thrombocytopenia) can indicate an increased risk of bleeding, while a high count (thrombocytosis) can be associated with clotting disorders.
(d) "Sedimentation rate checks for signs of cancer."
The erythrocyte sedimentation rate (ESR) measures how quickly red blood cells settle at the bottom of a test tube. It is a nonspecific test used to detect inflammation in the body. While an elevated ESR can be associated with various conditions, including infections, autoimmune diseases, and cancers, it is not specifically used to check for cancer. This statement indicates a misunderstanding of the purpose of the sedimentation rate test.
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