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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Ibuprofen is not recommended during pregnancy, especially in the later stages, as it can cause harm to the fetus and affect amniotic fluid levels.
Choice B rationale
While hydration is crucial for managing Hyperemesis Gravidarum, 0.9% Sodium Chloride alone won't address the underlying symptoms like nausea and vomiting effectively.
Choice C rationale
Magnesium Sulfate is typically used to prevent seizures in preeclampsia, not for Hyperemesis Gravidarum.
Choice D rationale
Pyridoxine (vitamin B6) is often recommended for Hyperemesis Gravidarum as it can help reduce nausea and vomiting.
Correct Answer is B
Explanation
Choice A rationale
While rupturing membranes can be a concern, the primary issue with a vaginal exam in the presence of placenta previa is the risk of severe bleeding. This choice is partially correct but not the most accurate answer.
Choice B rationale
With placenta previa, the placenta covers the cervix, and a vaginal exam could easily disrupt it, leading to significant vaginal bleeding. This bleeding can be dangerous for both the mother and the baby, making this the most accurate reason to avoid a vaginal exam.
Choice C rationale
Infection risk is a concern with any invasive procedure, but it is not the primary reason to avoid a vaginal exam in the case of placenta previa. The main concern is the risk of bleeding.
Choice D rationale
Initiating preterm labor is a possible risk with any vaginal exam late in pregnancy, but it is not the primary concern in cases of placenta previa. The main issue is the potential for causing severe bleeding.
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