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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.)

A.

Weight gain

B.

Visual disturbances

C.

Blood pressure

D.

Respiratory rate

E.

Deep tendon reflexes

F.

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.


View Related questions

Correct Answer is ["B","E","F"]

Explanation

Choice A rationale:

The statement suggests supplementing with formula due to the baby’s weight loss. However, a 5% weight loss in the first few days is normal for breastfed infants, and formula

supplementation is not necessary unless recommended by a healthcare provider. Early breastfeeding should be encouraged to increase milk supply and support newborn weight gain.

Choice B rationale:

This statement correctly indicates that newborns should feed 8 to 12 times per day and on demand to ensure adequate nutrition and promote milk production. Frequent breastfeeding

helps establish and maintain milk supply.

Choice C rationale:

Using plastic-lined breast pads can retain moisture and increase the risk of infection or irritation. Sore nipples can be managed with lanolin creams, air-drying, and proper latching

techniques during breastfeeding.

Choice D rationale:

Drinking more whole milk is a common misconception and does not directly increase a mother's milk supply. Milk production is influenced by frequent breastfeeding, proper hydration,

and balanced nutrition, not by specific types of foods or drinks.

Choice E rationale:

Newborn stools transition from dark greenish meconium to yellow, seedy stools within the first few days of life as breastfeeding becomes established. This indicates effective feeding

and milk intake.

Choice F rationale:

It is normal for a breastfeeding mother’s breasts to feel full, warm, and slightly tender as her milk comes in. This indicates that the milk supply is increasing and the body is responding

to the newborn’s feeding needs.

Correct Answer is B

Explanation

Choice A rationale

Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as

current treatments pose risks without guaranteed efficacy.

Choice B rationale

Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by

transferring through contact with cat feces.

Choice C rationale

While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.

Choice D rationale

Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.