A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

A nurse working in labor and delivery is assisting in the care of a client who is at 30 weeks of gestation.

Exhibits
Select the 5 findings that the nurse should recommend for follow-up.

A.
Persistent headache

B.
Nausea and vomiting

C.
Right epigastric pain

D.
Slight facial edema

E.
Heart rate of 88/min

F.
Blood pressure of 140/90 mmHg

G.
Proteinuria 2+

H.
Deep tendon reflexes (DTR) 3+ bilaterally

The Correct answer and Explanation is:

In this scenario, a nurse caring for a client at 30 weeks of gestation needs to identify findings that warrant follow-up. The correct five findings that should be recommended for follow-up are:

1. Persistent headache (A)
2. Right epigastric pain (C)
3. Blood pressure of 140/90 mmHg (F)
4. Proteinuria 2+ (G)
5. Deep tendon reflexes (DTR) 3+ bilaterally (H)

Explanation:

1. Persistent Headache (A): Headaches during pregnancy can be common, but a persistent headache may indicate a serious condition, such as preeclampsia. This condition can lead to severe complications for both the mother and the fetus. Therefore, this symptom should be closely monitored and followed up.
2. Right Epigastric Pain (C): This finding could be a sign of liver involvement associated with preeclampsia or HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). The right upper quadrant pain is concerning and requires further evaluation to rule out serious complications.
3. Blood Pressure of 140/90 mmHg (F): This blood pressure reading is considered elevated for a pregnant woman, suggesting possible gestational hypertension or preeclampsia. Hypertension in pregnancy requires monitoring and intervention to prevent complications like placental abruption or fetal distress.
4. Proteinuria 2+ (G): The presence of protein in the urine is an important marker for preeclampsia. A reading of 2+ indicates that the kidneys may be affected, warranting further evaluation and monitoring of the mother’s and fetus’s health.
5. Deep Tendon Reflexes (DTR) 3+ Bilaterally (H): Increased DTRs can indicate hyperreflexia, which is often associated with neurological changes in preeclampsia. This finding should be followed up to assess for possible seizure activity (eclampsia) and other neurological complications.

In contrast, nausea and vomiting (B), slight facial edema (D), and a heart rate of 88/min (E) are relatively common and not necessarily alarming in the absence of other symptoms. While facial edema should be monitored, slight facial swelling is often normal in pregnancy unless associated with other concerning signs.