A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago. Which of the following findings should the nurse report to the provider?
Pedal edema
BP of 132/84 mm Hg
Weight gain of 1 kg (2.2 lb)
Double vision
The Correct Answer is D
(a) Pedal edema
Pedal edema, or swelling of the feet and ankles, is a common finding during pregnancy due to increased fluid retention and pressure on the lower extremities from the growing uterus. While pedal edema should be monitored, it is not typically a concerning finding unless it is severe or accompanied by other symptoms suggestive of preeclampsia.
(b) BP of 132/84 mm Hg
A blood pressure of 132/84 mm Hg is within the normal range for pregnancy. However, if the client's blood pressure continues to increase or is accompanied by other symptoms of hypertension, such as proteinuria or headaches, it may warrant further evaluation.
(c) Weight gain of 1 kg (2.2 lb)
Weight gain during pregnancy is expected and can vary from person to person and from week to week. A weight gain of 1 kg (2.2 lb) over the course of a month is within the normal range for pregnancy and may not require immediate reporting to the provider unless there are other concerning symptoms.
(d) Double vision
Double vision (diplopia) can be a symptom of several conditions, including preeclampsia, which is a serious complication of pregnancy characterized by high blood pressure and proteinuria. Double vision can also be caused by other neurological or ophthalmologic conditions. Given its potential association with preeclampsia and other serious conditions, the nurse should promptly report double vision to the provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(a) Touch the corner of the newborn's mouth:
Touching the corner of the newborn's mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the touch and open their mouth, which helps with feeding.
(b) Place the newborn supine and apply pressure to the soles of the feet:
Applying pressure to the soles of the feet is not a method used to elicit the Babinski reflex. This action might influence other reflexes but not the Babinski.
(c) Stroke upward on the lateral aspect of the sole of the newborn's foot:
This is correct. The Babinski reflex is elicited by stroking upward on the lateral aspect of the sole of the newborn's foot. A positive response is the fanning and extension of the toes, which is normal in newborns.
(d) Pull the newborn up by the wrist from a supine position:
Pulling the newborn up by the wrists from a supine position is used to assess the traction response or pull-to-sit maneuver, which tests the newborn's head control and muscle tone, not the Babinski reflex.
Correct Answer is B
Explanation
(a) "I will need to start chemotherapy immediately."
Chemotherapy is not typically the first line of treatment for a molar pregnancy unless there is evidence of persistent gestational trophoblastic disease (GTD) or choriocarcinoma, which requires further evaluation and monitoring before making such a decision. This statement indicates a misunderstanding of the typical course of treatment after a molar pregnancy.
(b) "I will need to attend a support group when I get home."
Attending a support group can provide emotional support and coping strategies for individuals recovering from a molar pregnancy. It reflects an understanding of the importance of psychosocial support during recovery.
(c) "I will need an amniocentesis within 1 month."
Amniocentesis is not a routine follow-up procedure for a molar pregnancy. Follow-up typically includes serial measurements of hCG levels to ensure they return to normal and remain stable, which helps in monitoring for potential malignancy. This statement indicates a misunderstanding of the follow-up care required after a molar pregnancy.
(d) "I will need home palliative services after I am discharged from the hospital."
Home palliative services are generally not needed for patients recovering from a molar pregnancy, as the condition does not usually necessitate end-of-life care. This statement indicates a misunderstanding of the recovery process and the type of care required after a molar pregnancy.
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