101 mm Hg

Querry: Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)

Weight gain

Visual disturbances

Blood pressure

Respiratory rate

Deep tendon reflexes

Fetal heart rate

Question Solution

Correct Answer : A,B,E

Choice A rationale:

Rapid weight gain during pregnancy, especially when accompanied by other symptoms, can be a sign of preeclampsia. This condition is characterized by high blood pressure and often occurs after 20 weeks of gestation. Reporting rapid weight gain is important for early detection and management.

Choice B rationale:

Visual disturbances, such as blurred vision, can be a warning sign of preeclampsia. It indicates potential neurological involvement and requires immediate evaluation to prevent complications for both the mother and the fetus.

Choice C rationale:

Elevated blood pressure readings are a critical sign of preeclampsia, a condition that can lead to serious health complications for both the mother and the baby if left untreated. Reporting elevated blood pressure is essential for early intervention and management.

Choice D rationale:

While the respiratory rate is slightly elevated, it is not as critical an indicator of preeclampsia as the other findings. In this case, the focus should be on more concerning symptoms, such as blood pressure and visual disturbances.

Choice E rationale:

Hyperactive deep tendon reflexes (3+) are a clinical sign of preeclampsia. The absence of clonus is a reassuring sign, but the presence of hyperactive reflexes warrants further evaluation and monitoring.

Choice F rationale:

The fetal heart rate (FHT) of 148/min is within the normal range (110-160/min) and does not indicate an immediate concern that needs to be reported. The nurse should focus on the maternal symptoms that suggest preeclampsia.

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A. Open heart surgery. B. Tissue trauma from childbirth. C. Diabetes mellitus. D. Preeclampsia.

Correct Answer is B

Explanation

Choice A rationale

Open heart surgery is unrelated to the development of vaginal fistulas.

Choice B rationale

Tissue trauma from childbirth can cause vaginal fistulas, as prolonged labor or obstetric interventions can damage vaginal tissue and lead to fistula formation.

Choice C rationale

Diabetes mellitus does not directly cause vaginal fistulas, although it can affect overall tissue health and healing.

Choice D rationale

Preeclampsia, while a serious pregnancy complication, is not a direct cause of vaginal fistulas.

A. Assist the client to the bathroom to void. B. Ask the client to rate her pain. C. Encourage the client to move to the left lateral position. D. Encourage the client to perform Kegel exercises.

Correct Answer is A

Explanation

Choice A rationale

A boggy and displaced fundus typically indicates bladder distention. Assisting the client to void can help relieve bladder distention, allowing the uterus to contract properly and

reducing the risk of postpartum hemorrhage.

Choice B rationale

Asking the client to rate her pain is important, but it does not address the immediate issue of a boggy, displaced fundus, which suggests bladder distention.

Choice C rationale

Encouraging the client to move to the left lateral position might help with blood flow and comfort but does not resolve the issue of a boggy fundus due to bladder distention.

Choice D rationale

Kegel exercises strengthen pelvic floor muscles but do not address the immediate concern of a boggy, displaced fundus caused by bladder distention.

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A nurse is caring for a client with a new diagnosis of a vaginal fistula. The client states, "I don't understand how I got this.”. Which of the following is a potential cause of a vaginal fistula?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum and finds the fundus boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia. Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on October 17. What is the client's EDB? (State the date in MMDD. For example, October 17 is 1017)

A 38-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks gestation. Assessment findings include: blood pressure 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min. The nurse suspects preeclampsia. What additional finding would the nurse assess for?

A nurse is walking by a client's room and can hear the fetal heart rate dropping. The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?

A nurse is caring for a client whose pregnancy was complicated by polyhydramnios and is now 5 hours postpartum following a vaginal birth. The nurse should recognize that this client is at risk for which of the following postpartum complications?

A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

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