Exhibits

A nurse is reviewing the medical record of a client who has COPD. The nurse should notify the provider about which of the following findings? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale for correct choices:

• Blood pressure: A reading of 148/94 mm Hg is elevated and meets criteria for gestational hypertension, especially in a client who is gravida 1 para 0. It raises concern for preeclampsia and must be closely monitored, particularly with concurrent symptoms like headache and edema.
• DTR: A deep tendon reflex of 3+ is considered hyperreflexic and may signal increased central nervous system irritability. In the setting of elevated blood pressure and other preeclampsia signs, it raises concern for worsening severity or impending seizure activity.
• Lower extremity assessment: The presence of 1+ dependent edema can be a normal pregnancy finding, but when paired with facial swelling, recent weight gain, and elevated blood pressure, it becomes significant and suggests fluid retention associated with preeclampsia.
• Weight assessment: A gain of 0.68 kg (1.5 lb) in a week may seem modest, but when it is sudden and combined with facial and dependent edema, it can indicate abnormal fluid accumulation. This pattern is concerning for preeclampsia and requires follow-up.
• Nausea: While nausea is common in pregnancy, its presence along with right upper quadrant pain and headache raises red flags for severe preeclampsia or HELLP syndrome. These are warning signs of potential hepatic involvement or worsening disease.

Rationale for incorrect choices:

• Fundal height: A fundal height of 29 cm is consistent with gestational age around 29 weeks and does not indicate an abnormal finding in this context. No follow-up is needed unless measurements are inconsistent with gestational dating.
• Respiratory assessment: The client’s lungs are clear to auscultation and respirations are even and non-labored. Oxygen saturation is 95% on room air, which is within normal range during pregnancy, so no respiratory issues require intervention.
• Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 beats per minute. There are no reported decelerations or signs of distress, so no immediate follow-up is indicated for the fetal tracing.

Rationale for correct choices:

• A change in mood: Mood changes, including depression, irritability, or suicidal thoughts, are serious adverse effects associated with isotretinoin use. Adolescents are particularly vulnerable to these side effects, and any mood alterations during treatment warrant immediate provider notification.
• Decreased night vision: Isotretinoin can lead to visual disturbances, including decreased night vision, which may be sudden and irreversible. This adverse effect is rare but serious, and any signs of visual impairment should be reported promptly to prevent injury or permanent damage.

Rationale for incorrect choices:

• The development of dry eyes: Dry eyes are a common and expected side effect of isotretinoin, often due to mucous membrane dryness. While uncomfortable, it is not typically dangerous and can usually be managed with lubricating eye drops or supportive care without immediate provider contact.
• Dry mouth: Dry mouth occurs frequently with isotretinoin due to its drying effects on mucosal surfaces. It is bothersome but not dangerous, and clients can manage it with increased fluid intake and sugar-free lozenges. It doesn’t require urgent medical attention unless severe.
• Nausea: Nausea is not a common or concerning side effect of isotretinoin. If persistent or severe, it may require evaluation, but it is not a priority symptom for immediate provider contact unless accompanied by other warning signs like abdominal pain or jaundice.
• Sunburn: Increased photosensitivity is an expected effect of isotretinoin, and clients should be advised to wear sunscreen and protective clothing. Sunburn, while uncomfortable, is not an emergency and does not require immediate medical consultation unless it becomes severe.
• Worsening of acne: An initial acne flare is a known and expected part of isotretinoin therapy as pores begin to purge. This typically improves after several weeks and does not indicate treatment failure or require immediate provider notification unless accompanied by signs of infection.
• Engagement in sexual activity: While not a symptom, sexual activity is significant for female clients due to isotretinoin's teratogenicity. However, since this client has a negative hCG and is not sexually active, this is part of routine risk counselling not an immediate concern unless pregnancy is possible.