A nurse is providing care at a routine visit for a 28-year-old female client who is at 36 weeks of gestation in the clinic.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
Cerebral manifestations
Fetal heart rate
Deep tendon reflexes
Gastrointestinal assessment findings
Respiratory rate
Blood pressure
Correct Answer : A,D,F
Choice A rationale:
Cerebral manifestations, such as headaches and dizziness, can be indicative of severe preeclampsia, a condition that requires immediate attention to prevent complications for both the mother and the fetus.
Choice B rationale:
The fetal heart rate of 155 bpm is within the normal range for a fetus at 36 weeks of gestation (110-160 bpm). Therefore, this finding is not necessarily abnormal or concerning, and does not need immediate reporting to the provider.
Choice C rationale:
Deep tendon reflexes (DTRs) of 3+ are slightly brisk, but the absence of clonus makes this finding less concerning for severe preeclampsia or eclampsia, so it does not need immediate reporting.
Choice D rationale:
Gastrointestinal assessment findings, such as right upper quadrant pain and persistent "heartburn," are concerning for possible HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe form of preeclampsia that requires immediate attention.
Choice E rationale:
The respiratory rate of 20/min is within normal limits for an adult (12-20 breaths per minute) and does not indicate an immediate concern that needs to be reported to the provider.
Choice F rationale:
The blood pressure of 156/90 mm Hg is elevated and indicative of hypertension, which is concerning for preeclampsia and requires immediate attention to prevent complications for the mother and fetus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Placenta previa leads to painless vaginal bleeding when the placenta covers the cervix. It does not typically require continuous fetal monitoring or prepare for cesarean birth based on the findings alone.
Choice B rationale
Abruptio placentae is the premature detachment of the placenta, causing abdominal pain, and can lead to fetal distress. Continuous fetal monitoring and preparation for cesarean birth are consistent with this complication.
Choice C rationale
Gestational hypertension is high blood pressure that develops after 20 weeks of pregnancy but without the presence of protein in the urine or other symptoms of preeclampsia. It would not typically necessitate the measures described.
Choice D rationale
Preeclampsia involves high blood pressure and proteinuria after 20 weeks of gestation and can cause severe complications for both the mother and fetus. However, it does not directly lead to the specific intervention of continuous fetal monitoring and cesarean preparation. .
Correct Answer is D
Explanation
Choice A rationale
Asthma is a respiratory condition and is not directly linked to an increased risk of placental abruption. While chronic conditions can affect pregnancy, asthma is not a direct risk factor for abruption.
Choice B rationale
Hyperthyroidism is a thyroid condition that can cause complications during pregnancy, but it is not a known risk factor for placental abruption. It affects the mother's metabolism and can impact fetal development, but does not typically cause placental detachment.
Choice C rationale
Previous cesarean delivery is associated with risks such as uterine rupture in future pregnancies, but not specifically with placental abruption. The scar tissue from a cesarean may affect the placenta's position, but does not increase the risk of abruption directly.
Choice D rationale
Hypertension, or high blood pressure, is a significant risk factor for placental abruption. It can damage the blood vessels in the placenta, leading to separation from the uterine wall and resulting in abruption, which can be dangerous for both mother and baby.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.