The nurse is assessing a 25-year-old primigravida who is 20 weeks ...

[Jipu 123]

The nurse is assessing a 25-year-old primigravida who is 20 weeks pregnant. Which vital signs finding should the nurse report immediately to the physician?
 
  1. Pulse 88/min
  2. Respirations 30/min
  3. Blood pressure 134/82
  4. Temperature 37.4C (99.3F)

Question 2

The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings?
 
  1. Have the healthcare provider see the client today.
  2. Instruct the client to avoid direct sunlight.
  3. Document the findings on the prenatal chart.
  4. Analyze previous thyroid hormone laboratory results.

[shailee]

Answer to Question 1

2
Explanation:
1. A slight increase in pulse is an expected finding during pregnancy due to the increased oxygen consumption to support fetal metabolism.
2. Tachypnea is not a normal finding and requires medical care.
3. The blood pressure is within normal limits.
4. A slightly elevated temperature is an expected finding during pregnancy due to the increased oxygen consumption to support fetal metabolism.

Answer to Question 2

1
Explanation:
1. Mottling of the skin is indicative of poor oxygenation and a circulation problem. Skin and nail bed pallor can indicate either hypoxia or anemia. These abnormalities must be reported to the healthcare provider immediately.
2. Spider nevi are common in pregnancy due to the increased vascular volume and high estrogen levels. Nasal passages can be inflamed during pregnancy from edema, caused by increased estrogen levels.
3. These abnormalities must be reported to the healthcare provider immediately.
4. The thyroid gland increases in size during pregnancy due to hyperplasia.

[Jipu 123]

Thank you

[shailee]

Happy to help you