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) Restrict fluids to 1,000 mL/day:
Restricting fluids may lead to dehydration, which can exacerbate nausea and other symptoms of morning sickness. It is important for pregnant individuals to stay hydrated, so fluid restriction is not recommended unless otherwise directed by a healthcare provider.
(B) Take an over-the-counter antacid:
While antacids may provide relief for heartburn or indigestion, they are not typically recommended as a first-line treatment for nausea associated with morning sickness. Antacids may have limited effectiveness in managing nausea, and their use should be guided by a healthcare provider.
(C) Increase intake of fresh fruits:
While fresh fruits are nutritious and provide essential vitamins and minerals, they may not be well-tolerated by individuals experiencing morning sickness, especially if they have strong flavors or odors. Encouraging the client to eat bland foods in the morning may be more effective in managing nausea during early pregnancy.
(D) Eat dry, bland foods in the morning:
Encouraging the client to eat dry, bland foods in the morning can help alleviate nausea associated with morning sickness. These foods are generally easier on the stomach and less likely to trigger nausea compared to richer or spicier foods. Examples include crackers, toast, or dry cereal. Eating small, frequent meals throughout the day can also help manage nausea associated with pregnancy.
Correct Answer is A
Explanation
(A) Retained placental fragments:
Retained placental fragments can lead to postpartum hemorrhage (PPH) due to incomplete expulsion of the placenta or membranes, which can cause ongoing bleeding. Failure of the uterus to contract effectively after childbirth to compress blood vessels at the placental site can result in excessive bleeding. This is a significant risk factor for PPH and requires prompt intervention to prevent complications.
(B) Urinary tract infection:
While urinary tract infections (UTIs) can occur in the postpartum period, they are not typically considered significant risk factors for postpartum hemorrhage. UTIs are more commonly associated with symptoms such as dysuria, frequency, and urgency.
(C) Oligohydramnios:
Oligohydramnios, a condition characterized by decreased amniotic fluid volume, is not a direct risk factor for postpartum hemorrhage. Oligohydramnios may be associated with other pregnancy complications but is not directly related to the risk of postpartum hemorrhage.
(D) Breech presentation:
While breech presentation (when the baby's buttocks or feet are positioned to deliver first) may increase the risk of complications during labor and delivery, it is not specifically linked to postpartum hemorrhage. Breech presentation may necessitate interventions such as cesarean section delivery to reduce the risk of birth-related complications, but it is not a direct risk factor for postpartum hemorrhage.
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