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
(D) "I might be experiencing preterm labor if walking stops my contractions."
Walking or changing positions may temporarily alleviate contractions in some cases, but this does not necessarily indicate preterm labor. In fact, true preterm labor contractions typically continue despite activity changes. Therefore, this statement does not demonstrate an accurate understanding of preterm labor signs.
Correct Answer is D
Explanation
(A) Diuresis:
Diuresis, or increased urine production, is not a typical adverse effect of nalbuphine hydrochloride. Opioids generally do not affect urine output in the same way as diuretic medications.
(B) Fever:
Fever is not a common adverse effect of nalbuphine hydrochloride. If a client develops a fever during labor, it could indicate other underlying causes such as infection or inflammation, but it is not directly related to the administration of this medication.
(C) Diarrhea:
Diarrhea is not a typical adverse effect of nalbuphine hydrochloride. Opioid medications are more commonly associated with constipation due to their effects on gastrointestinal motility and function.
(D) Sedation:
Nalbuphine hydrochloride is an opioid analgesic used for pain relief during labor. Sedation is a common adverse effect of opioid medications, including nalbuphine. Opioids can depress the central nervous system, leading to drowsiness, sedation, and decreased level of consciousness. It's essential for the nurse to monitor the client closely for signs of sedation, especially during labor, to ensure the safety of both the mother and the baby.
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