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 A
Explanation
Potential Condition: Preterm labor. Based on the information provided, the patient is most likely experiencing preterm labor. Actions to Take: Administer tocolytics. If the patient is in preterm labor, the nurse should administer tocolytics to try to stop the contractions. Parameters to Monitor: Frequency of contractions. The nurse should monitor the frequency of contractions to assess the patient’s progress.
Correct Answer is A
Explanation
If the umbilical cord is protruding from the vagina, it’s a medical emergency known as cord prolapse. The nurse should insert a gloved hand into the vagina to relieve pressure on the cord. This is done to prevent cord compression, which could cut off the baby’s oxygen supply.
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.