The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus.
What is the priority when assessing this infant?

Choice A rationale

The presence of varicose veins (dilated, tortuous superficial veins) is a common finding during pregnancy due to increased venous pressure and is a risk factor for deep vein thrombosis (DVT). While it warrants monitoring for local signs of inflammation or pain, it is a chronic condition and not an acute sign of a severe complication like a pulmonary embolism (PE).

Choice B rationale

Dyspnea (difficulty breathing) is an acute and concerning symptom, especially in a client with a recent deep vein thrombosis (DVT), as it is a cardinal sign of a pulmonary embolism (PE). A PE occurs when a clot, often originating in the leg, embolizes and obstructs the pulmonary vasculature. This is a life-threatening complication that requires immediate intervention.

Choice C rationale

A pulse of 92 beats/min is slightly elevated but often an expected physiologic response in the postpartum period due to cardiovascular readjustment or mild pain/stress. While tachycardia can be a sign of a pulmonary embolism, a rate of 92 is not severe enough on its own to be the most concerning finding compared to acute respiratory distress (dyspnea). The normal adult pulse rate is 60 to 100 beats/min.

Choice D rationale

A blood pressure of 136/88 mm Hg is considered elevated (prehypertensive or stage 1 hypertension) but is not immediately life-threatening. While it requires follow-up, it is less acutely concerning than dyspnea, which suggests a severe respiratory or circulatory compromise like a pulmonary embolism. The client is not currently in a hypertensive crisis (e.g., ≥ 180/120 mm Hg).

Choice A rationale

Following the evacuation of a hydatidiform mole, the client is at risk for developing gestational trophoblastic neoplasia (GTN). Pregnancy must be avoided for at least six to twelve months to ensure that any persistent or new human chorionic gonadotropin (hCG) elevation is due to GTN and not a new normal pregnancy. Three months is the minimum duration often discussed.

Choice B rationale

Follow-up care, including weekly hCG level monitoring until the level is undetectable, then monthly for six to twelve months, is crucial for early detection of malignant transformation (choriocarcinoma). Therefore, six weeks of follow-up care is insufficient for proper surveillance and risk management.

Choice C rationale

A history of a hydatidiform mole is indeed a risk factor for recurrence, with a recurrence rate of approximately 1–2%. However, the immediate priority for discharge teaching focuses on preventing the hCG confounding effect of a new pregnancy and ensuring compliance with the necessary hCG monitoring protocol.

Choice D rationale

Chemotherapy is indicated if the hCG levels plateau or increase, or if there is evidence of metastasis, rather than if they decrease. A decrease in hCG levels is the desired outcome after evacuation and indicates successful treatment without the need for chemotherapy.