A nurse is assisting with the care of a female client who is at 36 weeks of gestation in the obstetrics office.

Select the 3 findings that require follow-up. (Select only 3)

Choice a rationale:

The blood pressure reading of 144/96 mm Hg at 36 weeks of gestation represents a significant elevation from the baseline of 118/76 mm Hg recorded two weeks ago. In pregnancy, a systolic pressure ≥ 140 mm Hg or a diastolic pressure ≥ 90 mm Hg is a diagnostic criterion for gestational hypertension or preeclampsia. This requires immediate follow-up to prevent complications such as placental abruption, stroke, or progression to eclampsia. Monitoring for protein in the urine and other systemic symptoms is the next clinical priority.

Choice b rationale:

The client reported feeling contractions at 0900, but the assessment at 1215 shows a relaxed fundus and no visible contractions on the external fetal monitor. While contractions are a concern for preterm labor, the physical findings currently indicate they are not active or at least not frequent enough to be captured. Since the more pressing issue is the neurological and cardiovascular changes suggesting preeclampsia, the lack of current contractions makes this a lower priority for immediate follow-up compared to the hypertensive symptoms.

Choice c rationale:

The client statements regarding a terrible headache, fuzzy vision, and photophobia (needing sunglasses) are critical red flags for central nervous system irritability. These are classic premonitory signs of preeclampsia with severe features. Visual disturbances and persistent headaches result from cerebral edema or vasospasm within the brain's vasculature. These symptoms significantly increase the risk of seizures (eclampsia). Therefore, these subjective reports require urgent follow-up and diagnostic testing to ensure maternal and fetal safety and to determine the need for magnesium sulfate.

Choice d rationale:

The fundal assessment noted that the fundus is relaxed to palpation. A relaxed fundus is a normal finding when a patient is not in active labor and helps rule out uterine tachysystole or a rigid, board-like abdomen associated with concealed placental abruption. While fundal height is usually monitored for fetal growth, a relaxed fundus in this acute context is a reassuring sign rather than an abnormal finding requiring urgent intervention. It indicates that the current physical distress is not likely due to uterine hypertonicity.

Choice e rationale:

The client reported no fluid leakage or bleeding. The absence of these findings is reassuring as it helps rule out the premature rupture of membranes or active vaginal bleeding, which could indicate labor or placental issues. Because the client explicitly denies these symptoms and there is no clinical evidence to contradict her, this does not require immediate follow-up. The focus remains on the positive symptoms the client is currently exhibiting, such as hypertension and visual changes, rather than the absence of other complications.

Choice f rationale:

The fetal heart rate (FHR) is 146/min, which falls well within the normal baseline range of 110 to 160/min. This indicates that the fetus is currently stable and not showing signs of acute distress despite the mother's hypertensive symptoms. While continuous monitoring is standard in high-risk situations, a normal FHR is a baseline expectation and does not itself constitute a finding that requires urgent follow-up or intervention at this specific moment in the assessment.

Choice g rationale:

The presence of bilateral dependent edema and the client's report that their feet and ankles were more swollen upon waking are significant. While mild edema is common in late pregnancy, sudden or worsening edema, especially when occurring in the morning or involving the face and hands, is associated with preeclampsia. It indicates fluid shifts and vascular permeability changes. Given the concurrent high blood pressure and neurological symptoms, this edema is a physical manifestation of a systemic process that requires thorough clinical investigation.

Choice h rationale:

The absence of bleeding is a negative finding that suggests the placenta remains intact and there is no immediate cervical change causing "bloody show." Much like the lack of fluid leakage, the absence of bleeding is a reassuring sign during the assessment. Because there is no reported or observed bleeding, it is not a finding that requires follow-up. The nursing priority must stay centered on the actual abnormal findings present, which point toward a hypertensive disorder of pregnancy that could compromise the client.

Choice A rationale

Choice A rationale:

Systemic hypertension is not a primary contraindication for the initiation of post-exposure prophylaxis medications. While specific antiviral agents might require monitoring of renal or hepatic function, which can be influenced by long-term poorly controlled blood pressure, the immediate need to prevent viral replication takes precedence. Patients with high blood pressure can safely undergo the 28-day regimen provided their clinical status is monitored by a healthcare provider for any drug-to-drug interactions with existing antihypertensives.

Choice B rationale

Choice B rationale:

The efficacy of post-exposure prophylaxis is highly time-dependent, as it must be initiated as soon as possible after a potential exposure to human immunodeficiency virus. Waiting up to 2 weeks would render the treatment ineffective because the virus would have already integrated into the host genome and established a permanent infection. Clinical guidelines strongly recommend starting the medication within 72 hours of exposure to maximize the chance of preventing viral replication and systemic spread.

Choice C rationale

Choice C rationale:

Effectiveness of post-exposure prophylaxis depends on strict adherence to the prescribed dosing schedule for a full 28-day duration. This timeframe is scientifically based on the period required to ensure that any virus introduced into the body is unable to complete its replication cycle and establish a reservoir. Skipping doses or ending the treatment early significantly increases the risk of seroconversion, allowing the virus to become a chronic infection despite the initial preventative efforts.

Choice D rationale

Choice D rationale:

Percutaneous exposure, such as a needle stick injury involving contaminated blood, represents a significant transmission risk for human immunodeficiency virus. The virus can be directly introduced into the bloodstream through the puncture site, bypassing the body's primary skin barriers. Therefore, a needle stick exposure is a primary indication for starting a post-exposure prophylaxis regimen immediately to reduce the probability of the virus becoming established within the lymphatic system and the rest of the body.