The nurse is examining a client who is 37 weeks pregnant. Which of the following findings would require immediate intervention by the nurse?

Question

1. Patellar reflex 4+/0-4+ bilaterally
2. Heart rate 104
3. Trace protein in the urine
4. Weight gain of 2 pounds in 2 months

Answer 1

1
Rationale 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.
Rationale 2: Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate.
Rationale 3: 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.
Rationale 4: Weight gain of 2 pounds in an 8-week period is not excessive and does not require immediate action.