Item 1 of 6
Question 1 of 6
Scenario
The following scenario applies to the next 6 items. The nurse is caring for a 34-year-old pregnant client.
Health History
A 34-year-old client who is 36 weeks pregnant and a G1P0 arrives at labor and delivery reporting a severe headache that "won't go away" despite taking acetaminophen, and blurry vision for the past several hours. She also reports mild epigastric pain and states her rings "haven't fit for the past 2 days." She denies vaginal bleeding, leaking of fluid, or contractions. Her prenatal history is significant for a body mass index (BMI) of 33 and this is a twin pregnancy (dichorionic-diamniotic). Her blood pressure at her prenatal visit 4 days ago was 128/82 mmHg. She has no other significant past medical history and takes only a prenatal vitamin.
Assessment — Day 1: 1400
| System | Findings |
|---|---|
| Neurologic | Alert and oriented x3; reports 8/10 headache; hyperreflexia (3+) with 2 beats of clonus |
| Respiratory | Clear breath sounds, symmetrical, unlabored |
| Cardiovascular | S1, S2 present; no murmur |
| Gastrointestinal | Bowel sounds normoactive x4; reports epigastric tenderness to palpation |
| Extremities | 3+ pitting edema in bilateral hands and feet; facial edema noted |
| Reproductive/Genitourinary | Fundal height 37 cm; no vaginal bleeding or fluid leakage; urine positive for 3+ protein on dipstick |
Vital Signs — Day 1: 1400
| Vital Sign | Value |
|---|---|
| Temperature | 98.6°F (37.0°C) |
| Heart Rate | 92 bpm |
| Respiratory Rate | 18/min |
| Blood Pressure | 168/112 mmHg |
| Pulse Oximetry | 97% on room air |
Select the top 4 findings that would require immediate follow-up.
0 of 6 items answered. Answers and rationales are revealed only after you submit the test.