Question

A nurse at a provider's office is caring for a client who is 28 years of age.

Select the 3 findings that require immediate follow-up.

History and Physical
Day 1 at 1000:
Gravida 3, Para 2, Abortion 1
Asthma (managed with levalbuterol inhaler as needed)
Pelvic inflammatory disease (PID)
Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)
Voluntary termination of pregnancy (3rd pregnancy)

Nurses' Notes
Day 1 at 1000:
Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting.

Vital Signs
Day 1 at 1000:
Temperature 37.2° C (98.9° F), Heart rate 90/min, Respirations 16/min, Blood pressure 120/74 mm Hg, Oxygen saturation 97% room air


A. Heart rate
B. Abdomen assessment
C. Respiratory assessment
D. Vaginal spotting
E. Bowel sounds
F. Menstrual period
G. Oxygen saturation
H. Temperature

Answer 1

Final answer:

The three findings that require immediate follow-up are:

A. Heart rate

B. Abdomen assessment

D. Vaginal spotting

Step-by-step explanation:

In the given scenario, the client presents with late menses, abdominal pain, and scant dark red vaginal spotting. The heart rate is noted to be 90/min, which is within the normal range. However, considering the client's history of hypertension during her first pregnancy, close monitoring of the heart rate is essential to rule out any cardiovascular concerns.

The abdomen assessment reveals tenderness in the right lower quadrant, indicating a potential issue that requires immediate attention. Given the client's history of spontaneous vaginal deliveries and pelvic inflammatory disease, prompt evaluation is necessary to rule out complications such as ectopic pregnancy or pelvic infection.

Vaginal spotting, as reported by the client, is another concerning finding. While the amount is described as scant, the combination of late menses and abdominal pain raises the possibility of a gynecological issue that requires immediate follow-up, such as a threatened miscarriage or other reproductive health concerns.

In summary, monitoring the heart rate, conducting a thorough abdomen assessment, and addressing the vaginal spotting are crucial steps to ensure the well-being of the client. These findings warrant immediate attention to identify and address any potential complications