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.
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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the healing of the placental site is a part of the postpartum recovery process, it does not directly correlate with the return of menstruation.
Choice B rationale
Ovulation does need to resume for menstruation to return, but the timing of ovulation resuming postpartum can vary greatly among individuals and does not provide a specific timeframe.
Choice C rationale
For a postpartum client who is formula-feeding her new baby, menstruation typically resumes six to eight weeks after birth.
Choice D rationale
While it is possible for menstruation to resume four weeks after birth, this is less common. The typical timeframe for the return of menstruation for a postpartum client who is formula- feeding is six to eight weeks.
Correct Answer is C
Explanation
Choice A rationale
While it’s true that phytonadione, also known as vitamin K, plays a role in the immune system, this is not the primary reason it is given to newborns. Therefore, this statement does not show an understanding of why the medication is being given.
Choice B rationale
Phytonadione does not aid an immature liver. It is necessary for the synthesis of certain proteins required for blood clotting. However, it does not directly aid the liver’s function.
Choice C rationale
This is the correct statement. Phytonadione is given to newborns to prevent hemorrhagic disorders, specifically vitamin K deficiency bleeding (VKDB). Newborns are at risk for VKDB because their gut does not yet have the bacteria necessary to produce vitamin K5.
Choice D rationale
While it’s true that vitamin K is obtained from dietary intake, newborns do not receive phytonadione to compensate for insufficient dietary intake. They receive it to prevent VKDB, a bleeding disorder caused by vitamin K deficiency.
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