A nurse is caring for a client who is pregnant in a provider’s office.

Relevant vital signs to help answer the questions are as follows: Medical History: 0830 Gravida 3 Para 2, 32 weeks of gestation, Allergies: Penicillin, Height: 163 cm, Weight: 78 kg, 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) 1. Which of the following findings should the nurse report to the provider? Select all that apply.

Rationale for Choice A:
It is accurate that scheduling the NST when the baby is usually active is beneficial. This is because fetal movement is expected to cause accelerations in the fetal heart rate, which is a positive sign of fetal well-being.
By scheduling the test during a time of typical fetal activity, the chances of obtaining a reactive NST (a normal result) are increased.
Therefore, this statement does not indicate a need for further teaching.

Rationale for Choice B:
Lying on the back during the NST is not recommended.
This position can cause the weight of the uterus to compress the major blood vessels (the inferior vena cava and aorta), potentially reducing blood flow to the placenta and fetus.
Reduced blood flow can, in turn, lead to a decrease in fetal heart rate and movement.
To avoid this, the recommended position for NST is a semi-Fowler's position, which involves being partially reclined with the head and upper body elevated.
This position helps to promote uterine perfusion and prevent supine hypotension.

Rationale for Choice C:
It is accurate that the baby's heart rate will be monitored during the NST.
This is the primary purpose of the test: to assess the fetal heart rate response to fetal movement. Therefore, this statement does not indicate a need for further teaching.

Rationale for Choice D:
It is accurate that the client will be able to go to the bathroom during the NST if necessary. The test is noninvasive and does not require strict immobility.
The client can move around and use the bathroom as needed, as long as the fetal heart rate monitor is not disconnected.
Therefore, this statement does not indicate a need for further teaching.

Condition

• A. Preeclampsia is the most likely condition the client is experiencing given the following:
  • History of gestational diabetes and mild hypertension.
  • Recent elevation in blood pressure.
  • Preeclampsia is characterized by high blood pressure and can be associated with kidney involvement, as suggested by the increased blood pressure.

Actions

1. Administer prescribed antihypertensive medication: This is crucial for managing preeclampsia, as it helps lower blood pressure and prevent complications.

2. Monitor blood pressure and urine protein levels regularly: Essential for assessing the progression of preeclampsia and guiding treatment decisions. Monitoring helps track whether the condition is worsening or responding to treatment.

Parameters to Monitor

1. Blood pressure readings: These are directly related to the severity of preeclampsia and help assess if the treatment is effective.

2. Level of protein in urine: Elevated protein levels indicate kidney involvement, which is a common complication of preeclampsia.