51. A nurse in an antepartum clinic is caring for a client who is pregnant.
Medical History 0815:
Gravida 4 Para 3
33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)
BMI 30.6
3.2 kg (7 lb) weight gain over the last 2 weeks
Select the 4 assessment findings the nurse should report to the provider.
Deep tendon reflexes
Visual disturbances
Fetal heart rate
Blood pressure
Weight
Correct Answer : C,D,E
Visual disturbances in a pregnant client could indicate conditions such as preeclampsia or gestational hypertension, which require immediate medical attention.
Monitoring the fetal heart rate is essential to assess fetal well-being, and any abnormalities in the fetal heart rate may require further evaluation by the provider.
Changes in blood pressure, especially elevated blood pressure, may indicate gestational hypertension or preeclampsia, which require monitoring and management by the provider. A significant weight gain of 3.2 kg (7 lb) over the last 2 weeks may indicate fluid retention or other issues that need assessment and intervention by the provider.
Deep tendon reflexes (option A) are not typically assessed routinely in antepartum care unless there are specific indications, such as signs of preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This response does not respect the client's autonomy and right to confidentiality.
B. This response acknowledges the client's feelings and opens up the opportunity for further discussion.
C. While it's important for parents to be informed about their child's health condition, especially if the adolescent is a minor, this response may escalate the client's anxiety and fear about disclosing their infection to their parents.
D. This response minimizes the client's concerns and may not accurately reflect the complexity of their situation.
Correct Answer is ["Moro reflex color of extremities head assessment maternal urine toxicology screen gluteal folds"]
Explanation
Subgaleal hemorrhage is a rare but potentially serious condition in newborns characterized by bleeding beneath the scalp's galea aponeurotica, a fibrous tissue layer between the scalp and the skull.
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