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 A

Explanation

Choice A rationale

Iron-deficiency anemia is a common nutritional issue among pregnant teenagers. During pregnancy, the body needs more iron to support the growth and development of the fetus. Teenagers, who are still growing themselves, may already have lower iron stores. Therefore, it is crucial to include information about the importance of iron and how to get enough from the diet in a nutrition education program for pregnant teenagers.

Choice B rationale

While gestational diabetes is a concern during pregnancy, it is not the most crucial topic for a nutrition education program specifically for pregnant teenagers. Gestational diabetes is a condition that can develop during pregnancy in women who don’t already have diabetes. It’s not as common in teenagers as it is in older women.

Choice C rationale

High cholesterol is generally not a primary concern during pregnancy. In fact, it’s normal for cholesterol levels to rise during pregnancy. However, long-term high cholesterol can increase the risk of heart disease.

Choice D rationale

Excessive weight gain can be a concern during pregnancy, but it is not the most crucial topic for a nutrition education program for pregnant teenagers. It’s normal and healthy to gain weight during pregnancy, but the amount should be carefully monitored. Excessive weight gain can lead to complications such as gestational diabetes or high blood pressure.

A. Hegar’s sign. B. Breast tenderness. C. Amenorrhea. D. Morning sickness.

Correct Answer is C

Explanation

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

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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

What is the most crucial topic for the nurse to include in a nutrition education program for pregnant teenagers?

Correct Answer is A

Explanation

A client informs the nurse that she believes she is pregnant. Which sign or symptom is the best indicator that the client is pregnant?

Correct Answer is C

Explanation

A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin.What side effect should the nurse instruct the client to report immediately?

The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

A client who is scheduled for induction of labor receives a prescription for oxytocin 2 milliunits/min intravenously (IV). The IV bag contains oxytocin 20 units in lactated Ringer’s 1 liter. How many mL/hour should the nurse program the infusion pump to deliver? .

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

A client at 35 weeks gestation complains of pain whenever the baby moves.The nurse notes the client’s temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation.What condition do these findings suggest?

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

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?