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 D
Explanation
(a) "You will not be able to eat or drink anything for 8 hours prior to the test."
There are no fasting requirements for a nonstress test. The client can eat and drink normally before the test. Nonstress tests do not require the same preparation as some other medical tests, such as fasting or dietary restrictions.
(b) "You will be required to lie flat on your back for the duration of the test."
Lying flat on the back can cause supine hypotension syndrome in pregnant women, which can lead to decreased blood flow to the fetus. Instead, clients are typically positioned in a semi-Fowler's or lateral position to avoid this issue.
(c) "You will receive medication through an IV line to stimulate contractions."
This describes a contraction stress test, not a nonstress test. A nonstress test involves monitoring the fetal heart rate in response to natural fetal movements without inducing contractions through medication.
(d) "You will press the provided button when you feel the baby moving during the test."
During a nonstress test, the client is instructed to press a button whenever they feel fetal movement. This helps the healthcare provider correlate fetal movements with changes in the fetal heart rate, which can indicate fetal well-being.
Correct Answer is A
Explanation
(A) Perform fundal massage:
Performing fundal massage is the highest priority action in this scenario. Complete saturation of the perineal pad within 30 minutes postpartum suggests excessive bleeding, which could indicate postpartum hemorrhage (PPH). Fundal massage helps to stimulate uterine contractions, which can aid in controlling bleeding by compressing blood vessels at the placental site. It is essential to assess the fundus for firmness and position and massage it if necessary, to prevent or manage PPH.
(B) Weigh the perineal pad:
Weighing the perineal pad can provide information about the amount of blood loss, but it is not the highest priority action at this moment. Fundal massage takes precedence to address the potential underlying cause of excessive bleeding.
(C) Apply oxygen by face mask:
While oxygen therapy may be indicated in certain situations, such as respiratory distress, it is not the highest priority in this scenario. The priority is to address the potential cause of excessive bleeding and prevent further complications associated with postpartum hemorrhage.
(D) Monitor urine output:
Monitoring urine output is an important aspect of postpartum care, but it is not the highest priority when the client is experiencing excessive bleeding. Addressing the potential cause of bleeding and preventing complications associated with postpartum hemorrhage take precedence.
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