A nurse is caring for a female client scheduled to have a pelvic exam. The client tells the nurse, “I’m really nervous.
I’ve never had a pelvic exam before.” Which of the following is an appropriate therapeutic response by the nurse?

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 A:
Purpose of the Biophysical Profile (BPP): The BPP is a non-invasive test that combines ultrasound and fetal heart rate monitoring to assess fetal well-being, specifically in the third trimester of pregnancy. It evaluates five parameters: fetal breathing movements, fetal body movements, fetal tone, amniotic fluid volume, and fetal heart rate reactivity. Each parameter is assigned a score of 0 or 2, resulting in a total score of 0 to 10. A score of 8 or 10 is generally considered reassuring of fetal well-being, while a score of 6 or below may warrant further evaluation or intervention.
Timing of BPP: It's typically performed in the third trimester, often after 32 weeks of gestation, when the fetus has developed regular sleep-wake cycles and breathing movements.
Risk Assessment: It's often recommended for pregnancies considered high-risk, such as those with: Maternal diabetes
Preeclampsia
Decreased fetal movement Past stillbirth
Multiple gestation
Oligohydramnios (low amniotic fluid) Post-term pregnancy (over 42 weeks)

Choice B:
IV initiation is not a routine part of BPP: Intravenous (IV) access is not typically required for a BPP. The test involves external monitoring of fetal heart rate and ultrasound imaging, which do not necessitate IV access.

Choice C:
NPO status is not necessary: The client does not need to be NPO (nothing by mouth) for a BPP. There are no dietary restrictions or fasting requirements for this test.

Choice D:
BPP does not determine the estimated date of birth: The primary purpose of the BPP is to assess fetal well-being, not to determine the estimated date of delivery (EDD). The EDD is typically established based on the last menstrual period or early ultrasound measurements.