The nurse is examining a client who is 37 weeks pregnant. Which ...

[Tirant22]

The nurse is examining a client who is 37 weeks pregnant. Which assessment finding would require immediate intervention by the nurse?
 
  1. Patellar reflex 4+/0 - 4+ bilaterally.
  2. Heart rate 104.
  3. Trace protein in the urine.
  4. Weight gain of two pounds in 2 months.

Question 2

The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB) for the baby. The client reports the last menstrual period (LMP) was May 10. Using Naegele Rule, which date will the nurse share with client?
 
  1. February 17.
  2. May 17.
  3. May 24.
  4. January 3.

[hanadaa]

Answer to Question 1

Correct Answer: 1
Hyperreflexia may be indicative of preeclampsia, and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate. Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need, or of the same level of importance of the reflex findings. Weight gain of two pounds in an 8-week period is not excessive and does not require immediate action.

Answer to Question 2

Correct Answer: 1
Using Naegele Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.