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.
Visual disturbances.
Fetal heart rate.
Blood pressure.
Deep tendon reflexes.
Correct Answer : A,C,D
Rationale for Choice A: Visual disturbances
Preeclampsia: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. It typically develops after 20 weeks of gestation and can progress rapidly.
Potential complications: If left untreated, preeclampsia can lead to seizures (eclampsia), stroke, liver and kidney failure, premature birth, and even death of the mother or baby.
Prompt reporting: Early recognition and management of preeclampsia are crucial for preventing adverse outcomes. Therefore, visual disturbances should be reported to the provider immediately to initiate further assessment and potential interventions.
Rationale for Choice B: Fetal heart rate
No indication for reporting: While monitoring fetal heart rate is essential during pregnancy, the promptness of reporting it to the provider depends on specific concerns. In this case, the fetal heart tones are documented as 1, suggesting a normal rate and rhythm. There's no immediate indication for reporting it as a concerning finding.
Rationale for Choice C: Blood pressure
Hypertension: High blood pressure is a key feature of preeclampsia. Although blood pressure readings are not provided in the scenario, the nurse should measure and report them to the provider, as hypertension is a critical finding that could necessitate further evaluation and treatment.
Rationale for Choice D: Deep tendon reflexes
Hyperreflexia: The client's deep tendon reflexes are 3+, which is considered hyperreflexia. Hyperreflexia can be a neurological sign of preeclampsia, indicating increased excitability of the nervous system. It's important to report this finding to the provider for further assessment and monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: The recommended weight gain for a woman with a normal BMI (18.5-24.9) during pregnancy is 25-35 pounds. This range ensures adequate nutrition for both the mother and the developing baby, supporting optimal fetal growth and maternal health.
Choice B rationale: A weight gain of 11-20 pounds is recommended for women with a high BMI (≥30) during pregnancy. This range helps minimize the risk of complications such as gestational diabetes and hypertension, but it is not applicable for a woman with a normal BMI.
Choice C rationale: While a healthy diet is crucial, specific weight gain guidelines are essential to ensure the health of both mother and baby. Weight gain recommendations are based on evidence to support optimal outcomes, making it important to follow them.
Choice D rationale: A weight gain of 15-25 pounds is recommended for women with an overweight BMI (25-29.9) during pregnancy. This range helps support fetal growth while minimizing the risk of complications, but it is not applicable for a woman with a normal BMI.
Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 60/min is a sign of bradycardia, which can be a side effect of magnesium sulfate toxicity. Magnesium sulfate slows down neuromuscular transmission, which can lead to a decrease in heart rate. If the heart rate drops too low, it can compromise blood flow to vital organs, including the brain and heart. Therefore, a heart rate of 60/min is not a safe finding that would indicate the nurse should continue the infusion.
Choice C rationale:
A urine output of 50 ml in 4 hours is indicative of oliguria, which is a decreased urine output. Oliguria can be a sign of magnesium sulfate toxicity, as magnesium is primarily excreted through the kidneys. If the kidneys are not functioning properly, magnesium can build up in the body and lead to toxic levels. Therefore, a urine output of 50 ml in 4 hours is not a safe finding that would indicate the nurse should continue the infusion.
Choice D rationale:
Diminished deep-tendon reflexes are another sign of magnesium sulfate toxicity. Magnesium sulfate suppresses the nervous system, which can lead to decreased reflexes. If the reflexes are too diminished, it can indicate that the magnesium level in the body is too high. Therefore, diminished deep-tendon reflexes are not a safe finding that would indicate the nurse should continue the infusion.
Choice B rationale:
A respiratory rate of 16/min is within the normal range for an adult. It does not indicate any respiratory depression, which can be a side effect of magnesium sulfate toxicity. Therefore, a respiratory rate of 16/min is a safe finding that would indicate the nurse can continue the infusion.
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