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  1. 29. A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

    Nurses' Notes

    0900:

    Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
    1000:

    Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale, Reports feeling dizzy when they got up from examination table
    Which of the following findings should the nurse report to the provider?

    (Select all that apply.)

A.

Cerebral manifestations

B.

Gastrointestinal assessment findings

C.

Respiratory rate

D.

Deep tendon reflexes

E.

Blood pressure

F.

Feral heart rate

Answer and Explanation

Correct Answer : A,B,C,E,F

A The client reports a mild headache initially but then experiences a more severe headache along with dizziness. These symptoms could preeclampsia or gestational hypertension.
B.    The client's presentations increase suspicion for preeclampsia which can lead to liver injury with right upper quadrant tenderness.

C.    It is important to assess the respiratory rate as part of the overall evaluation of the client's condition considering the potential involvement of conditions like preeclampsia, which can affect multiple body systems.
 
E.    The client's symptoms, including headache, dizziness, and inability to remove rings due to swelling, raise concerns for preeclampsia or gestational hypertension.
F.    Monitoring fetal well-being is essential in the assessment of maternal conditions such as preeclampsia. If there are any concerns about fetal well-being, they should be reported to the provider.


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Related Questions

Correct Answer is B

Explanation

Lochia rubra, which is bright red and may contain small clots, is the normal postpartum vaginal discharge that occurs during the first few days after childbirth. It indicates the shedding of the uterine lining and is expected during the early postpartum period. A midline and firm fundus at the level of the umbilicus suggests appropriate uterine involution, indicating that the uterus is contracting effectively to expel lochia and decrease in size.

Given these findings, there is no immediate concern requiring intervention.

Correct Answer is C

Explanation

The priority nursing goal is to maintain the integrity of the sac.

Myelomeningocele is a type of spina bifida where the spinal cord and its covering (meninges) protrude through an opening in the vertebrae, forming a sac on the baby's back. It is crucial to protect this sac from injury and infection to prevent complications such as meningitis and nerve damage.

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