A nurse in a provider's office is caring for a 32-year-old female client who is pregnant.
Medical History:
The client is a Gravida 3 Para 2, at 32 weeks of gestation. She has a known allergy to penicillin. She is 5 feet 4 inches (163 cm) tall and weighs 178 lb (80.7 kg), with a BMI of 30.6. The client reports a 6 lb weight gain over the last 2 weeks. She has had a headache for 5 days, blurred vision, and dizziness, which Tylenol does not relieve. The client reports swelling of her feet and fingers. She has 2+ pitting edema of the lower extremities noted bilaterally, and swelling of the fingers and hands is noted. Deep tendon reflexes are 3+, absent clonus. Fetal heart tones (FHT) are 148/min.
Vital Signs:
0800:
Temperature: 36.6°C (97.9°F)
Pulse rate: 88/min
Respiratory rate: 20/min
Blood Pressure: 179/99 mm Hg
0815:
Pulse rate: 82/min
Respiratory rate: 16/min
Blood Pressure: 168/104 mm Hg
0830:
Pulse rate: 81/min
Respiratory rate: 16/min
Blood Pressure: 170/101 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
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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View Related questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
B. Remove the newborn from phototherapy every 4 hours for thorough assessment of adverse effects of phototherapy.
D. Maintain an eye mask over the newborn's eyes.
E. Reposition the newborn every 2 hours.
F. Report sunken fontanels to the provider. Contraindicated:
A. Apply lotion to the skin every 4 hours.
C. Newborn feedings should be every 8 hours.
Correct Answer is D
Explanation
Choice A rationale
Administering the rubella vaccine during pregnancy, including the third trimester, is contraindicated due to the risk of live vaccine transmission to the fetus. It is not recommended at any stage of pregnancy.
Choice B rationale
Advising the client to get the vaccine during her next pregnancy attempt is partly correct but lacks the immediacy needed to ensure she is immune before the next pregnancy. The vaccine should be given postpartum.
Choice C rationale
Administering the vaccine immediately during pregnancy is contraindicated due to potential risks to the fetus. Rubella vaccines contain live virus, which can cause fetal harm if given during pregnancy.
Choice D rationale
It is safest to administer the rubella vaccine postpartum, prior to hospital discharge, to ensure the client has immunity before any future pregnancies. This timing prevents any risk to the current fetus and ensures future fetal protection. .