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
Explanation
Choice A rationale
Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.
Choice B rationale
A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.
Choice C rationale
A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.
Choice D rationale
Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.
Correct Answer is C
Explanation
Choice A rationale
A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.
Choice B rationale
A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.
Choice C rationale
Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.
Choice D rationale
A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.