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    Ati rn comprehensive predictor 2023 proctored exam
    Select All That Apply

    A nurse in labor and delivery is caring for a client who is at 30 weeks of gestation. Select the 5 findings that require follow-up by the nurse.

    Explanation & Rationale

    A. Weight assessment: The client gained 0.68 kg (1.5 lb) in one week, which may indicate rapid fluid retention. In the context of hypertension and edema, this requires follow-up for possible preeclampsia or fluid overload. B. Respiratory assessment: Respirations are even, non-labored, and oxygen saturation is 95%, which is within acceptable limits for 30 weeks of gestation. No immediate follow-up is indicated based solely on these findings. C. Fundal height: The fundal height is 29 cm at 30 weeks gestation, 29 cm at 30 weeks is within the expected range (usually +/- 2 cm of the week of gestation). D. Lower extremity assessment: The client has 1+ dependent edema bilaterally. Combined with hypertension and facial edema, this finding may indicate fluid retention associated with preeclampsia, requiring monitoring and further evaluation. E. Blood pressure: The client’s blood pressure is 148/94 mm Hg, which is elevated for pregnancy. Hypertension at 30 weeks can indicate preeclampsia and requires prompt assessment and intervention. F. Nausea: While common in early pregnancy, nausea and vomiting in the third trimester—especially when paired with right upper abdominal pain—suggest liver involvement or Glisson's capsule stretching, which are "severe features" of preeclampsia/HELLP syndrome. G. Fetal heart tracing: Fetal heart rate is 140/min with no contractions, which is within normal limits for gestation. No immediate follow-up is necessary based on this assessment. H. DTR: Deep tendon reflexes are 3+ bilaterally, indicating hyperreflexia. This is a concerning sign for preeclampsia and requires prompt follow-up to prevent complications such as seizures.

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