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.

Exhibits

Which of the following findings should the nurse report to the provider? (Select all that apply.)

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.