A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.
The client reports a mild headache for the last several days as well as “heartburn”. The client denies visual disturbances, vaginal bleeding, or leakage of fluid from the vagina.
The client reports occasional contractions and positive fetal movement.
The client reports they are unable to remove rings from fingers for the last several days. The client reports feeling dizzy when they got up from the examination table.
Which of the following findings should the nurse report to the provider? (Select all that apply)
Cerebral manifestations.
Gastrointestinal assessment findings.
Respiratory rate.
Deep tendon reflexes.
Correct Answer : A,B,D
Choice A rationale
Cerebral manifestations such as a mild headache can be a sign of preeclampsia, a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the liver and kidneys. This should be reported to the provider.
Choice B rationale
Gastrointestinal assessment findings such as heartburn can be common in pregnancy due to hormonal changes and the growing uterus pressing on the stomach. However, severe or persistent heartburn may indicate a more serious condition like gastroesophageal reflux disease (GERD) or preeclampsia. This should be reported to the provider.
Choice C rationale
Respiratory rate alone, without knowing whether it’s increased, decreased, or normal, is not enough information to determine if it should be reported to the provider.
Choice D rationale
Deep tendon reflexes can be hyperactive in clients with preeclampsia. An increase in deep tendon reflexes can be a sign of worsening preeclampsia and should be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a pattern of contractions can be a sign of labor, it is not the definitive sign of true labor. Contractions may also occur in false labor, also known as Braxton Hicks contractions. These contractions do not lead to changes in the cervix.
Choice B rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are the definitive signs of true labor. During true labor, contractions lead to progressive changes in the cervix, which allow for the baby to be born.
Choice C rationale
Rupture of the membranes, or “water breaking,” can occur in both true labor and false labor. Therefore, it is not the definitive sign of true labor.
Choice D rationale
The station of the presenting part refers to the position of the baby’s head (or other presenting part) in relation to the mother’s pelvis. While the station can change during labor as the baby descends into the pelvis, it is not the definitive sign of true labor.
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.
Choice B rationale
While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.
Choice D rationale
Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.
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