Exhibits

The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

Choice A rationale

Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.

Choice B rationale

Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.

Choice C rationale

Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.

Choice D rationale

Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.

Complete the sentence: The nurse teaches the client about the fetus's reaction to labor by explaining that early decelerations indicate head compression and assessing fetal heart rate patterns before, during, and after contractions.

Rationale for correct answer: Explaining that early decelerations indicate head compression is correct because early decelerations are typically associated with head compression during contractions. This is a common finding during labor and usually not a sign of fetal distress. It indicates that the fetus is descending through the birth canal, causing temporary compression of the fetal head, which leads to a brief decrease in heart rate.

Assessing fetal heart rate patterns before, during, and after contractions is correct because it provides a comprehensive understanding of how the fetus responds to labor. Monitoring the fetal heart rate throughout the contraction cycle helps identify patterns of variability, decelerations, and accelerations, ensuring that the fetus is tolerating labor well.

Rationale for incorrect answers: Choice A rationale: Identifying early decelerations as a sign of fetal distress is incorrect because early decelerations are generally benign and related to head compression. They are not typically a sign of fetal distress. Late or variable decelerations are more concerning and may indicate fetal distress.

Choice C rationale: Stating that early decelerations require immediate intervention is incorrect because early decelerations do not usually require immediate intervention. They are a normal finding during labor caused by head compression. Interventions are necessary for late or variable decelerations, which indicate possible fetal compromise.

Choice D rationale: Noting that early decelerations suggest umbilical cord compression is incorrect because early decelerations are not typically associated with umbilical cord compression. Variable decelerations are more likely to indicate cord compression, requiring closer monitoring and possible intervention.