— 降低風險 · MEDIUM · SATA —
護理師評估一位懷孕 34 週的病人，哪些發現需回報醫師？（選所有適合的）
A nurse is collecting data from a client at 34 weeks gestation. Which findings should the nurse report to the provider? (Select all that apply.)
- AEpigastric pain✓ 正解上腹痛
- BVisual disturbances such as blurred vision✓ 正解視力障礙，如視力模糊
- COccasional dependent edema in the feet足部偶爾出現下垂性水腫
- DBlood pressure reading of 150/98 mmHg✓ 正解血壓讀數為 150/98 mmHg
- EFetal movement felt throughout the day整天感受到胎動
— Explanation · 中文詳解 —
懷孕 34 週出現上腹痛（Epigastric pain）、視力模糊（Visual disturbances）與高血壓（Hypertension），是子癇前症（Preeclampsia）進展為重度子癇前症的關鍵警訊。上腹痛反映肝臟包膜受損或腫脹，視力模糊則與腦水腫相關，均為發生癲癇前的危險徵兆。護理師須立即回報並採取預防癲癇發作的護理措施。
At 34 weeks of gestation, epigastric pain, visual disturbances, and hypertension are key warning signs that preeclampsia is progressing toward severe preeclampsia. Epigastric pain reflects hepatic capsular distention or swelling, and blurred vision is associated with cerebral edema; both are dangerous prodromes of eclamptic seizures. The nurse must report these findings immediately and institute seizure precautions.