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 A
Explanation
Choice A:
Fetal heart tone location: In a frank breech presentation, the fetal buttocks are positioned downward and the legs are extended straight up toward the head, placing the fetal heart closer to the mother's upper abdomen. This results in fetal heart tones being heard above the umbilicus at midline.
Gestation period: At 9 weeks of gestation, the fetus is still small and has ample room to move within the uterus, making breech presentations more common. However, it's important to note that the ideal position for childbirth is cephalic, with the head down.
Other presentations:
Cephalic presentations typically have fetal heart tones below the umbilicus.
Transverse presentations usually have fetal heart tones laterally, off to one side of the abdomen.
Posterior presentations, while still head down, can have fetal heart tones that are difficult to locate or muffled due to the position of the fetal back against the mother's spine.
Choice B:
Fetal position: In a transverse presentation, the fetus is positioned horizontally across the uterus, with the head and buttocks on either side. This typically results in fetal heart tones being heard laterally, rather than above the umbilicus at midline.
Choice C:
Fetal position: In a cephalic presentation, the fetus is head down, with the buttocks near the fundus of the uterus. This usually results in fetal heart tones being heard below the umbilicus, rather than above it.
Choice D:
Fetal position: In a posterior presentation, the fetus is head down, but facing the mother's back. While this can sometimes make fetal heart tones difficult to locate, they are typically still heard below the umbilicus, rather than above it.
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