A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
The client reports a mild headache for the last several days as well as “heartburn”. The client denies visual disturbances, vaginal bleeding, or leakage of fluid from the vagina.
The client reports occasional contractions and positive fetal movement.
The client reports they are unable to remove rings from fingers for the last several days. The client reports feeling dizzy when they got up from the examination table.
Which of the following findings should the nurse report to the provider? (Select all that apply)
Cerebral manifestations.
Gastrointestinal assessment findings.
Respiratory rate.
Deep tendon reflexes.
Correct Answer : A,B,D
Choice A rationale
Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.
Choice B rationale
Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.
Choice C rationale
Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.
Choice D rationale
Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Elevating the leg can help reduce swelling and improve blood flow, which can alleviate pain and redness in the calf. This is a non-pharmacological intervention that the client can easily do at home.
Choice B rationale
Applying cold compresses is typically used for acute injuries to reduce inflammation and numb the area. However, in the case of a postpartum client reporting pain and redness in her calf, this could potentially be a sign of a deep vein thrombosis (DVT), and applying cold compresses may not be the most appropriate intervention.
Choice C rationale
Flexing the knee while resting is not typically recommended for a client with symptoms that may indicate a DVT. This position does not promote venous return and could potentially exacerbate the condition.
Choice D rationale
Massaging the area is not recommended if a DVT is suspected, as it could dislodge a blood clot and cause a pulmonary embolism.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.
Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.
Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.
Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.
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