A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation. Select the 5 findings that the nurse should recommend for follow-up.
Explanation & Rationale
A. Respiratory data: The client’s respirations are even and nonlabored, with clear lung sounds and an oxygen saturation of 94% on room air. Although the respiratory rate is mildly elevated, there are no signs of pulmonary edema or respiratory compromise requiring immediate follow-up. B. Lower extremity data: The presence of 1+ dependent edema bilaterally can be a normal finding in pregnancy due to increased fluid volume and venous stasis. In isolation, this level of edema does not indicate a critical concern requiring urgent follow-up. C. Nausea: Nausea and vomiting in the third trimester, especially when accompanied by headache and right epigastric pain, are concerning for severe preeclampsia. These symptoms suggest hepatic involvement and warrant prompt follow-up and evaluation. D. Deep tendon reflex: Hyperreflexia with 3+ deep tendon reflexes indicates increased neuromuscular irritability. This finding is associated with preeclampsia and increases the risk for seizure activity, making it a priority for follow-up. E. Blood pressure: A blood pressure of 156/96 mm Hg meets the criteria for hypertension in pregnancy. Persistent elevations place the client at risk for preeclampsia and related complications and require immediate provider notification. F. Fundal height: At 30 weeks’ gestation, an expected fundal height is approximately 30 cm. A measurement of 26 cm suggests possible intrauterine growth restriction, which may be related to placental insufficiency and requires further assessment. G. Weight data: A weight gain of 0.68 kg (1.5 lb) in one week may indicate abnormal fluid retention. Rapid weight gain in pregnancy is a concerning sign of worsening preeclampsia and should be followed up promptly.