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.
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.
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