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.
You might also like to view...
Patients receiving chloroquine (Aralen Phosphate) for malaria prophylaxis should receive patient teaching from the nurse, which includes instructions to receive what regularly?
A) Cardiovascular studies B) Eye exams C) Immunizations D) Pulmonary studies
A teenager is accompanied by the mother to the annual physical examination. The nurse is aware of privacy issues related to the teenager
While the mother is in the room, the nurse should avoid questions about which of the following topics? Select all that apply. 1. Sexual activity 2. Cigarette smoking 3. School performance 4. Alcohol use 5. Use of car seat belts
When assessing the family of a client recently diagnosed with schizophrenia, the nurse notes that they mention feeling hopeless and frustrated. The nurse knows that this is known as:
A) Guilt. B) Subjective family burden. C) Objective family burden. D) Shame.
When the nurse learns that the assigned clients include a child with aplastic anemia, the nurse knows that this is a condition involving:
a. production of an inadequate number of erythrocytes b. lack of, or deficiency in, factor V c. circulation of highly moldable platelets d. production of inadequate amounts of hemoglobin