A nurse is assessing four clients in a prenatal clinic.
Which of the following clients should the nurse recommend that the provider see first?
A client who is at 12 weeks of gestation and reports not having felt the fetus move.
A client who is at 28 weeks of gestation and has a fetal heart rate of 160/min via Doppler.
A client who is at 38 weeks of gestation and has 2+ deep tendon reflexes.
A client who is at 36 weeks of gestation and reports blurred vision.
The Correct Answer is D
Choice A rationale
A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.
Choice B rationale
A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.
Choice C rationale
Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.
Choice D rationale
Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
Correct Answer is B
Explanation
Choice A rationale
Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.
Choice B rationale
Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.
Choice C rationale
Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.
Choice D rationale
Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.
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