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 C
Explanation
Choice A rationale:
A negative test implies a non-reactive NST, meaning the fetal heart rate (FHR) did not demonstrate the expected accelerations in response to fetal movements.
However, the scenario states that fetal movements were noted, and decelerations were observed. Decelerations, even lasting 30 seconds, are not consistent with a negative test.
Choice B rationale:
A positive test is not a standard term used in the context of NST results.
The term "positive" is more often associated with tests that identify a specific condition or abnormality.
NST results are typically classified as reactive or non-reactive, with further interpretation based on the presence or absence of decelerations and other FHR patterns.
Choice C rationale:
A reactive NST is the desired outcome, indicating a healthy fetal response to movement.
It requires two or more FHR accelerations of at least 15 beats per minute for a minimum of 15 seconds, each within a 20- minute period.
Although the decelerations lasting 30 seconds warrant further assessment, they do not negate the presence of the required accelerations, making the test reactive.
Choice D rationale:
"Non-reactive deceleration of rising in the fetal heart rate during a period" is not a standard NST result terminology.
It incorrectly combines elements of non-reactivity (lack of accelerations) with a description of decelerations, which are distinct FHR patterns.
Correct Answer is B
Explanation
The correct answer is choice b. Placenta previa.
Choice A rationale:
Threatened abortion typically occurs in the first trimester and involves vaginal bleeding with or without abdominal pain. It is not associated with late pregnancy bleeding.
Choice B rationale:
Placenta previa is characterized by painless, bright red vaginal bleeding in the third trimester. It occurs when the placenta covers the cervix, leading to bleeding as the cervix begins to dilate.
Choice C rationale:
Preterm labor involves uterine contractions leading to cervical changes before 37 weeks of gestation. While it can cause bleeding, it is usually accompanied by regular contractions and not typically described as bright red bleeding.
Choice D rationale:
Abruptio placentae involves the premature separation of the placenta from the uterine wall, leading to painful, dark red vaginal bleeding. It is often associated with abdominal pain and uterine tenderness, which differentiates it from placenta previa.
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