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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Respiratory rate.
Choice A rationale:
Fetal heart rate (FHR) is an important assessment for clients experiencing preterm labor, but it is not the priority assessment when administering magnesium sulfate. FHR monitoring is crucial to ensure fetal well-being but is not directly related to the potential adverse effects of magnesium sulfate.
Choice B rationale:
Temperature is an essential assessment parameter, but it is not the priority in this case. Magnesium sulfate administration can cause adverse effects, particularly on the respiratory system, which should be closely monitored.
Choice C rationale:
Respiratory rate is the correct choice because respiratory rate is a priority assessment when administering magnesium sulfate. The drug can cause respiratory depression and other respiratory complications, so monitoring the respiratory rate is essential to ensure the client's safety.
Choice D rationale:
Bowel sounds are not a priority assessment for a client receiving magnesium sulfate. While gastrointestinal side effects can occur with magnesium sulfate use, respiratory assessments take precedence.
In conclusion, the priority nursing assessment for a client receiving magnesium sulfate is the respiratory rate due to the potential respiratory complications associated with the drug. Monitoring respiratory function closely can help prevent adverse outcomes and ensure the client's safety during treatment.
Correct Answer is A
Explanation
Choice A rationale
Turning the client onto her side is the first action the nurse should take when late decelerations are noted on the fetal monitor. Late decelerations can indicate uteroplacental insufficiency, and turning the client onto her side can improve placental blood flow and oxygen delivery to the fetus.
Choice B rationale
Increasing the client’s IV fluid infusion rate can help increase maternal blood volume and improve placental perfusion. However, it is not the first action to take when late decelerations are noted.
Choice C rationale
Palpating the client’s uterus can provide information about the strength, duration, and frequency of contractions, but it is not the first action to take when late decelerations are noted.
Choice D rationale
Administering oxygen to the client can increase the amount of available oxygen for fetal oxygenation. However, it is not the first action to take when late decelerations are noted.
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