A nurse is assisting with the care of a client in a provider's clinic.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

The client presents to clinic reporting a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well

Oriented ×4. Answers questions appropriately, follows simple commands Heart rate regular, S1 S2 auscultated. No abnormal heart sounds heard. Respiration even and unlabored. Lung sounds clear to auscultation. Abdomen soft, fat, normoactive bowel sounds in all four quad states, "appetite is good" and stools are soft and brown Reports voiding without difficulty, clear yellow urine. Reports last menstrual period was 3 months ago. Skin is warm and moist. Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately.

• Urine protein: The presence of 3+ proteinuria is a significant finding suggestive of preeclampsia. Protein in the urine indicates renal involvement due to endothelial dysfunction, which is a hallmark complication in hypertensive disorders of pregnancy and needs immediate attention.
• Respiratory rate: A respiratory rate of 16/min falls within the normal adult range of 12 to 20 breaths per minute. There is no evidence of respiratory distress, tachypnea, or bradypnea, so this finding does not suggest a prenatal complication.
• Gravida/parity: Although the client has a history of one preterm birth, gravida and parity alone are not indicators of a current prenatal complication. It is important background information but does not point directly to an acute complication at this time.
• Urine ketones: The absence of ketones in the urine is a normal finding. If ketones were present, it could suggest dehydration, starvation, or uncontrolled diabetes, but since they are negative, ketones are not a concern for prenatal complication here.
• Headache: A severe headache unrelieved by acetaminophen in a pregnant woman can signal worsening hypertension or preeclampsia. Persistent headaches are a concerning symptom that warrants immediate evaluation and management to prevent maternal and fetal harm.
• Fetal activity: Decreased fetal movement is a worrisome sign of possible fetal compromise, such as hypoxia or placental insufficiency. Reduced movements require further fetal assessment and monitoring to ensure fetal well-being.
• Blood pressure: A blood pressure reading of 162/112 mm Hg is severely elevated and meets the diagnostic criteria for severe preeclampsia. Uncontrolled hypertension during pregnancy places both the mother and fetus at significant risk for serious complications.

A. Crackles in the lung bases: Left-sided heart failure leads to fluid buildup in the lungs due to the heart's inability to pump blood effectively. This fluid accumulation causes pulmonary congestion, which results in crackles, particularly in the lung bases. This is a common and expected finding in left-sided heart failure.

B. Anorexia: Anorexia may occur in heart failure, but it is not a primary or typical finding of left-sided heart failure. It is more commonly associated with right-sided heart failure, where digestive system congestion is more prevalent.

C. Bradycardia: Left-sided heart failure typically causes tachycardia (elevated heart rate) as the body compensates for the decreased cardiac output. Bradycardia is less commonly seen unless the client has an underlying arrhythmia or is on medications like beta-blockers.

D. Polyuria during the day: Polyuria, or excessive urination, is typically observed at night (nocturia) in clients with heart failure due to fluid redistribution when lying down. It is not commonly observed during the day.