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A nurse in a provider's office is caring for a 32-year-old female client who is pregnant.

Exhibits

Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)

Weight gain

Visual disturbances

Blood pressure

Respiratory rate

Deep tendon reflexes

Fetal heart rate

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale:

Rapid weight gain during pregnancy, especially when accompanied by other symptoms, can be a sign of preeclampsia. This condition is characterized by high blood pressure and often occurs after 20 weeks of gestation. Reporting rapid weight gain is important for early detection and management.

Choice B rationale:

Visual disturbances, such as blurred vision, can be a warning sign of preeclampsia. It indicates potential neurological involvement and requires immediate evaluation to prevent complications for both the mother and the fetus.

Choice C rationale:

Elevated blood pressure readings are a critical sign of preeclampsia, a condition that can lead to serious health complications for both the mother and the baby if left untreated. Reporting elevated blood pressure is essential for early intervention and management.

Choice D rationale:

While the respiratory rate is slightly elevated, it is not as critical an indicator of preeclampsia as the other findings. In this case, the focus should be on more concerning symptoms, such as blood pressure and visual disturbances.

Choice E rationale:

Hyperactive deep tendon reflexes (3+) are a clinical sign of preeclampsia. The absence of clonus is a reassuring sign, but the presence of hyperactive reflexes warrants further evaluation and monitoring.

Choice F rationale:

The fetal heart rate (FHT) of 148/min is within the normal range (110-160/min) and does not indicate an immediate concern that needs to be reported. The nurse should focus on the maternal symptoms that suggest preeclampsia.

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Correct Answer is A

Explanation

Choice A rationale

Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) occurs when amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream, triggering a serious reaction. It can cause sudden shortness of breath, cardiovascular collapse, and other severe symptoms immediately after a rupture of membranes and is a rare but critical obstetrical emergency.

Choice B rationale

Abruptio placentae involves the premature separation of the placenta from the uterine wall, which leads to bleeding and potential fetal and maternal distress. However, it does not typically present with sudden cardiorespiratory collapse or shortness of breath immediately following membrane rupture.

Choice C rationale

Uterine rupture refers to a tear in the wall of the uterus, usually due to trauma, labor stress, or previous surgical scars. While it is a severe condition, it usually presents with abdominal pain, vaginal bleeding, and fetal distress rather than sudden respiratory failure.

Choice D rationale

Disseminated intravascular coagulation (DIC) is a condition affecting blood clotting processes, often secondary to other conditions like severe preeclampsia, sepsis, or trauma. It generally presents with bleeding and clotting issues but not sudden respiratory or cardiovascular collapse.

A. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.” B. "Look at how she looks at you when you speak. That's a good sign.” C. "We do routine hearing screenings on newborns. You'll know before you leave the hospital if additional evaluation is recommended.”. D. "There is no need to worry about that. Most forms of hearing loss are not inherited.”

Correct Answer is C

Explanation

Choice A rationale

Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.

Choice B rationale

While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.

Choice C rationale

Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.

Choice D rationale

This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.

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A nurse in a provider's office is caring for a 32-year-old female client who is pregnant. Exhibits Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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A nurse in a provider's office is caring for a 32-year-old female client who is pregnant.

Exhibits

Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)