A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.
What should the nurse do next?

Inspect the client’s face for edema.

Inquire about a history of cluster headaches.

Determine the frequency of headaches.

Monitor and time the client’s contractions.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A client at 32 weeks gestation reporting nausea, vomiting, and elevated blood pressure could be showing signs of a condition called gestational hypertension or preeclampsia. This condition can affect the health of both the mother and the baby, depending on how severe the issue is. Inspecting the client’s face for edema is a relevant next step because swelling in the face, hands, or fingers is a common symptom of preeclampsia.

Choice B rationale

While headaches can be a symptom of preeclampsia, asking about a history of cluster headaches may not be the most immediate concern in this situation. Cluster headaches are a specific type of headache that is not directly related to pregnancy or preeclampsia.

Choice C rationale

Determining the frequency of headaches could be useful in assessing the client’s overall health, but it may not be the most immediate concern when the client is showing potential signs of preeclampsia.

Choice D rationale

Monitoring and timing the client’s contractions would be more relevant if the client was in labor or showing signs of preterm labor. In this case, the client’s symptoms are more indicative of a hypertensive disorder of pregnancy.

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Correct Answer is D

Explanation

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

A. Clean up the spit-up and assist the mother with the diaper change. B. Position the newborn on the side and suction the mouth and nares with a bulb syringe. C. Position the newborn with the head lower than the feet. D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

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A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

Correct Answer is D

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

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The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.
What should the nurse do next?