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Select the 4 assessment findings the nurse should report to the provider.

Exhibits
A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits:

Headache for 2 days unrelieved by Tylenol.

Blurred vision and dizziness.

Swelling of feet.

2+ pitting edema of the lower extremities.

Deep tendon reflexes 3+, absent clonus.

Fetal heart tones 150/min.

Blood pressure of 180/99 mm Hg

Answer and Explanation

Correct Answer : A,B,D,G

Choice A rationale: A headache that lasts for 2 days and is not relieved by Tylenol is a concerning symptom in a pregnant client. This could 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. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal. Left untreated, preeclampsia can lead to serious — even fatal — complications for both mother and baby. Severe headaches are a common symptom of preeclampsia and should be reported to the healthcare provider immediately.

Choice B rationale: Blurred vision and dizziness are also symptoms of preeclampsia. These symptoms occur as a result of changes in the blood vessels in the brain due to high blood pressure. The brain relies on a healthy blood supply to function properly, and any disruption to this can lead to symptoms such as blurred vision and dizziness. These symptoms should be reported to the healthcare provider immediately as they may indicate a need for immediate treatment or monitoring.

Choice C rationale: While swelling of the feet is common in pregnancy due to fluid retention and increased blood flow, it is not typically a symptom that needs to be reported to the healthcare provider unless it is accompanied by other symptoms of preeclampsia or other complications. Swelling in the face and hands is more concerning than swelling in the feet.

Choice D rationale: 2+ pitting edema of the lower extremities is a sign of fluid overload in the body, which can be a symptom of preeclampsia. This should be reported to the healthcare provider as it may indicate a need for treatment or closer monitoring.

Choice E rationale: Deep tendon reflexes of 3+ and absent clonus are within normal limits for a pregnant client. Hyperreflexia (reflexes rated as 4+) and the presence of clonus could indicate neurological irritability associated with preeclampsia, but these findings are not present in this client.

Choice F rationale: Fetal heart tones of 150/min are within the normal range of 110-160 beats per minute. This is a reassuring sign and does not need to be reported to the healthcare provider.

Choice G rationale: A blood pressure of 180/99 mm Hg is significantly elevated and is a hallmark sign of preeclampsia. This should be reported to the healthcare provider immediately as it indicates severe preeclampsia, which requires immediate treatment to prevent complications such as eclampsia, placental abruption, and organ damage.

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Correct Answer is C

Explanation

Choice A rationale
Assisting with amnioinfusion is not the first priority. Amnioinfusion is a procedure where a sterile solution is introduced into the uterus to increase the volume of fluid around the fetus. It is typically used in cases of oligohydramnios (low amniotic fluid) or to dilute thick meconium in the amniotic fluid.
Choice B rationale
Inserting a scalp electrode is not the first priority. A scalp electrode is a device used to monitor the fetal heart rate more accurately. It is usually used when external monitoring does not provide a clear reading or when there is a need for continuous detailed monitoring.

Choice C rationale
Changing the woman’s position is the correct action. Late decelerations in the fetal heart rate can be a sign of uteroplacental insufficiency, a condition where the placenta cannot deliver adequate oxygen to the fetus. Changing the woman’s position can improve placental blood flow and potentially improve the oxygen supply to the fetus.
Choice D rationale
Notifying the health care provider is important but not the first priority. The nurse should first attempt interventions such as changing the woman’s position to improve the fetal heart rate.

A. Cocaine use B. Blunt force trauma C. Cigarette smoking D. Hypertension

Correct Answer is D

Explanation

Choice A rationale
Cocaine use is a risk factor for placental abruption, but it is not the most common one. Cocaine can cause vasoconstriction and decrease placental perfusion, leading to abruption.
Choice B rationale
Blunt force trauma, such as that from a car accident or physical violence, can cause placental abruption. However, it is not the most common risk factor.
Choice C rationale
Cigarette smoking is a risk factor for many pregnancy complications, including placental abruption. Smoking can impair placental function and lead to poor pregnancy outcomes.
Choice D rationale
Hypertension is the most common risk factor for placental abruption. High blood pressure can cause damage to the blood vessels in the placenta, leading to abruption.

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Select the 4 assessment findings the nurse should report to the provider.

Exhibits
A nurse in an antepartum clinic is caring for a client who is pregnant. Exhibits: