A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immediately to the provider?

Select all that apply.

A.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2.This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

B.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C.The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

D.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

E.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

F.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

G.The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.

H.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

I.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

J.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.

The correct answer is choice A. Persistent headache, B. Nausea and vomiting, C. Right epigastric pain, G. Proteinuria 2+, H. Deep tendon reflexes (DTR) 3+ bilaterally. Choice A rationale: Persistent headache is a significant symptom that can indicate increased intracranial pressure or other serious conditions, especially in a pregnant client. It requires follow-up to rule out complications such as preeclampsia. Choice B rationale: Nausea and vomiting, particularly when severe and persistent, can lead to dehydration and electrolyte imbalances. In the context of pregnancy, it can also be a sign of a more serious underlying condition that needs to be addressed. Choice C rationale: Right epigastric pain is concerning as it can be indicative of liver involvement, which is a serious complication in pregnancy. This symptom needs immediate follow-up to assess for conditions such as HELLP syndrome. Choice D rationale: Slight facial edema can be a normal finding in pregnancy, but it can also be a sign of fluid retention associated with preeclampsia. However, on its own, it is not as critical as the other symptoms listed. Choice E rationale: A heart rate of 88/min is within the normal range for adults and does not typically require follow-up unless accompanied by other concerning symptoms. Choice F rationale: Blood pressure of 140/90 mmHg is elevated and concerning in pregnancy, but it is not included in the correct answers because the other symptoms are more directly indicative of severe complications. Choice G rationale: Proteinuria 2+ is a significant finding that suggests kidney involvement and is a key diagnostic criterion for preeclampsia. This requires immediate follow-up. Choice H rationale: Deep tendon reflexes (DTR) 3+ bilaterally are hyperactive and can indicate neurological irritability, which is a concerning sign in the context of preeclampsia. This finding needs follow-up to prevent complications such as seizures. Choice I rationale: Fundal height measurement of 26 cm at 30 weeks of gestation is below the expected range and may indicate intrauterine growth restriction (IUGR) or other issues, but it is not as immediately critical as the other findings listed.