A nurse is reinforcing teaching with a client who is pregnant and has a prescription for Rho(D) immune globulin. Which of the following information should the nurse include?

Choice A rationale:

Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.

Choice B rationale:

Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.

Choice C rationale:

Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.

Choice D rationale:

Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.

Choice E rationale:

Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.

The cervix is dilated 3 cm: This indicates the width of the cervical opening, which is 3 cm wide.

It is effaced 30%: This means the cervix has effaced or thinned out by 30%, indicating how much the cervix has shortened and thinned in preparation for labor.

The presenting part is 1 cm above the ischial spines (indicated by the negative number, -1): This measurement shows the position of the baby's head in relation to the ischial spines of the pelvis. In this case, the baby's head is 1 cm above the ischial spines.
Option A ("The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines."): This option incorrectly interprets the baby's position as being 1 cm below the ischial spines, which is not the case. The negative sign (-1) in the documentation indicates that the presenting part is 1 cm above the ischial spines.

Option B ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines."): This option switches the interpretation of dilation and effacement. In the original documentation, the dilation is given as 3 cm, while effacement is 30%. This option incorrectly states that effacement is 3 cm and dilation is 30%. Additionally, it correctly identifies the presenting part's position.

Option C ("The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines."): This option correctly interprets effacement and dilation but incorrectly states that the presenting part is 1 cm below the ischial spines. The original documentation indicates that the presenting part is 1 cm above the ischial spines, as denoted by the negative sign (-1).