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: 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.

Choice B:

Implantation typically occurs 6 to 12 days after ovulation, not 2 to 3 weeks. This is a crucial distinction because it aligns with the developmental timeline of the early embryo and the physiological changes in the endometrium that prepare for implantation.

The timing of implantation is essential for establishing a viable pregnancy. If implantation occurs too early or too late, it can lead to complications such as early pregnancy loss or ectopic pregnancy.

Understanding the correct timing of implantation is vital for healthcare professionals to provide accurate information and guidance to clients regarding conception and early pregnancy.

Choice A:

Sperm can indeed remain viable in the woman's reproductive tract for up to 5 days. This means that intercourse that occurs several days before ovulation can still lead to conception.

The lifespan of sperm is important for understanding fertility and timing intercourse for those trying to conceive.

Choice C:

Fertilization does typically occur in the outer third of the fallopian tube, also known as the ampulla. This is where the sperm meets the egg, and fertilization takes place.

The location of fertilization is significant because it ensures that the fertilized egg, or zygote, has time to travel down the fallopian tube and implant in the uterus.

Choice D:

Bleeding can sometimes accompany implantation, known as implantation bleeding. This bleeding is usually light and occurs around the time of expected menstruation.

It is important to be aware of implantation bleeding as it can sometimes be mistaken for a menstrual period.