A nurse is caring for a client who is pregnant in a provider's office. Vital Signs. Medical History. 0830:. Medical History: Gravida 3 Para 2. 32 weeks of gestation. Allergies: Penicillin. Height 54, 163 cm. Weight 80.7 kg (178 lb). BMI 30.6. 6 lb weight gain over the last 2 weeks. The client reports, "I have had a headache for 5 days, blurred vision, and dizziness. Tylenol does not relieve it.". The client reports swelling of their feet and fingers. 2+ pitting edema of the lower extremities noted bilaterally. Swelling of the fingers and hands noted. Deep tendon reflexes 3+, absent clonus. Fetal heart tones (FHT) 148. Which of the following findings should the nurse report to the provider?
Visual disturbances.
Blood pressure.
Respirations.
Deep tendon reflexes.
Weight.
The Correct Answer is A
Choice A rationale:
Visual disturbances should be reported to the provider because the client is experiencing headaches, blurred vision, and dizziness, which can be signs of preeclampsia. Preeclampsia is a serious condition that can develop during pregnancy and is characterized by high blood pressure and damage to organs like the liver and kidneys. Visual disturbances may indicate neurological involvement and can pose a risk to both the client and the fetus.
Choice B rationale:
Blood pressure should be reported to the provider due to the client's symptoms and medical history. The client's weight gain, swelling of feet and fingers, and 2+ pitting edema suggest fluid retention, which can be associated with preeclampsia. High blood pressure is a key diagnostic criterion for preeclampsia, and the nurse must monitor it closely to assess the severity of the condition and the potential risk to both the client and the fetus.
Choice C rationale:
Respirations do not appear to be a significant concern based on the information provided. While respiratory status is important to monitor during pregnancy, there are no indications in the scenario to suggest respiratory distress or abnormalities that require immediate reporting to the provider.
Choice D rationale:
Deep tendon reflexes are mentioned in the client's medical history but do not show any immediate signs of concern. Absent clonus and 3+ deep tendon reflexes are within the normal range and not typically alarming during pregnancy. However, the nurse should continue to monitor these reflexes during subsequent visits.
Choice E rationale:
Weight gain is mentioned in the medical history but is not currently a critical finding to report. A 6 lb weight gain over 2 weeks may be considered appropriate for a pregnant client at 32 weeks of gestation, but it should be assessed in conjunction with other symptoms for a comprehensive evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, Maternal hypertension.
Choice A rationale:
Maternal hypertension is widely recognized as the most common risk factor for placental abruption. High blood pressure can cause the placenta to detach from the uterine wall, leading to abruption. In summary, while all the listed factors can contribute to the risk of placental abruption, maternal hypertension stands out as the most common cause, supported by multiple health sources. It’s important for nurses to recognize and manage hypertension in pregnant clients to minimize the risk of this serious complication.
Choice B rationale:
While maternal cocaine use is a significant risk factor for placental abruption due to its vasoconstrictive effects, which can compromise the placental blood flow, it is not as common as maternal hypertension.
Choice C rationale:
Maternal cigarette smoking is also a risk factor for placental abruption. Smoking can lead to a variety of complications in pregnancy, including placental problems, but again, it is less common than hypertension as a cause for abruption.
Choice D rationale:
Maternal battering can lead to trauma which may result in placental abruption. However, it is not considered the most common risk factor when compared to maternal hypertension.
Correct Answer is B
Explanation
Choice A rationale:
If the client is Rh positive and the newborn is Rh negative, there is no indication for administering Rho(D) immune globulin. Rho(D) immune globulin is only given when the Rh-negative mother gives birth to an Rh-positive baby.
Choice B rationale:
This is the correct choice for administering Rho(D) immune globulin. When the mother is Rh negative and the newborn is Rh positive, there is a risk of Rh incompatibility. If the fetal blood enters the mother's circulation during delivery, her immune system may produce antibodies against Rh-positive blood cells, which can be harmful to future Rh-positive pregnancies. To prevent this, Rho(D) immune globulin is administered to the Rh-negative mother shortly after delivery.
Choice C rationale:
If both the mother and the newborn are Rh-negative, there is no risk of Rh incompatibility. Rho(D) immune globulin is not required in this situation.
Choice D rationale:
If both the mother and the newborn are Rh-positive, there is no risk of Rh incompatibility. Rho(D) immune globulin is not indicated in this case.
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